LAPAROSCOPIC GASTRIC BYPASS ST. LUKE S HOSPITAL NEW YORK CITY, NEW YORK

Transcription

1 LAPAROSCOPIC GASTRIC BYPASS ST. LUKE S HOSPITAL NEW YORK CITY, NEW YORK February 13, :00:11 NARRATOR: An estimated six million Americans are affected by severe obesity; condition that has become a major public health issue resulting in three hundred thousand deaths a year. Bariatric surgery is the only proven technique to achieve long term weight loss in this population. During this live webcast, surgeons from St. Luke s Hospital in New York City will perform a laparoscopic gastric bypass procedure, a treatment option for morbid obesity. 00:00:35 JULIO TEIXEIRA MD: In terms of the basic principles of the operation, one, is to reduce the size of the stomach to a very small size, thus limiting the amounts of food that you can eat. And, two, it also helps to achieve weight loss by bypassing a part of the intestine, which results in the decrease in the absorption of the foods that you eat. Our operation is designed to improve safety. Safety today is a very important issue, particularly when we re doing an operation that may not be of emergent need in their life. So it s very important that when we do these types of procedures that we focus on safety. 00:01:14 NARRATOR: At any time throughout this program, you may questions to the physicians by clicking the M-Direct access button on the screen. 00:01:25 BLANDINE LAFERRERE MD: Welcome to St. Luke s Hospital in New York City. Today we will performing live, on the Internet, a laparoscopy gastric bypass, which is a weight loss procedure. I am Blandine Laferrere, an attending in the Department of Medicine, Division of Endocrinology, Diabetes and Nutrition at St. Luke s. And Dr. Julio Teixeira, the head of the Bariatric Division, who will be performing the procedure today. Doctor Teixeira, can you hear me? 00:01:52 JULIO TEIXEIRA MD: I can. Thanks Blandine. And welcome everyone to St. Luke s Roosevelt Hospital Center and to our operating room. I ll introduce you to our patient first. Our patient is a thirty-five year old female with a long history of clinically severe obesity, who has attempted weight loss by medical supervised diets over many years and has failed. She has significant complications of her obesity, which include diabetes, hypertension, hypercholesterolemia, or high levels of cholesterol, and she is currently on multiple medications that include things such as Zortex and Cozaar, [Metamorphin?] and Lipitor. So our goal is not only to have her reduce her weight, which is over a hundred pounds overweight, but to also help address some of these medical problems; particularly her diabetes, her hypercholesterolemia and her hypertension. 00:02:56 So, first of all, I just wanted to show you an outside view of our procedure. Essentially what we re doing here is a minimally invasive operation. And we have the ports already inserted. As you can see, these are small incisions through which Page 1 of 17

2 we can introduce tiny instruments to allow us to perform the operation without a large incision, which would otherwise be required. And the reasons why we do this is to avoid some of the complications associated with these types of procedures, particularly like wound infections, pulmonary complications, hernias associated with the incisions. And so the goal is that by doing the minimally invasively we can avoid some of the these pitfalls and provide the patient a faster recovery, easier return to their normal activities and a shorter hospital stay. 00:03:44 So our first step in this operation is really going to be to create a little tunnel here through which we will be introducing our so called [root?] limb or part of the intestine which will later on be attached to the stomach. And this is essentially a small part of the operation. You can see, again, at this point a small part of the pancreas here. And in a minute I ll show you a little bit more of the anatomy as well. 00:04:18 BLANDINE LAFERRERE MD: So this fat that you are cutting here is the what s called the visceral fat? 00:04:21 JULIO TEIXEIRA MD: It is essentially exactly, Blandine. That s exactly what it is. There you can see the pancreas there. And this is the visceral fat. And this essentially is also This patient, one of the complications that she has is the fact that she has what is called central obesity, or obesity that is mostly 00:04:42 BLANDINE LAFERRERE MD: The upper body obesity, right? Yeah. 00:04:44 JULIO TEIXEIRA MD: Exactly. 00:04:45 BLANDINE LAFERRERE MD: Yeah, that s the one that s most associated with metabolic complications. 00:04:50 JULIO TEIXEIRA MD: Essentially. So you see here, this is the back part of her stomach, in a sense, and the pancreas. We re going to go back upstairs. I just want to show you a little bit of her liver. The liver is also quite large. This is also a complication of her obesity. She had what we call fat infiltration of the liver. And so this, hopefully, also will be resolved through weight loss. So we re going to go The next step in this operation is really to then divide the small intestine, because we re going to create two parts of the small intestine; one of which will be used to connect to your future her future stomach and one which will be, again, it will be maintained for her nutritional absorption and to maintain her appropriate nutrition. So we re going to divide the intestines here. And we re going to The reason why we divide it very close to the beginning of the intestine is to preserve the amount of absorption, particularly some of the mineral nutrients such as calcium and and some of the other minerals like magnesium and zinc, which are absorbed very early in the small intestine. So we ll minimize the amount of nutritional deficiencies this patient will have. 00:06:13 And as you see, the bleeding usually at this point is very minimal. And throughout this operation, in general, we would expect very little bleeding. The instrument we re using is a harmonics scalpel that works through sound waves, so it really is not causing any significant burns to tissues. So the next step is creating our root limb, which we want to make it to our specific size so it will be able to achieve a specific amount of weight loss. 00:06:43 BLANDINE LAFERRERE MD: So what s the size that you usually use, Julio? Page 2 of 17

3 00:06:47 JULIO TEIXEIRA MD: It depends on the size of the patient. Patients who s BMI, or Body Mass Indexes, which I m sure you ll discuss with the audience a little bit later in terms of what it means. For patients with BMIs between forty and fifty, we ll we use a hundred centimeters. If the patient s BMI is greater, then sixty, we ll use a hundred and fifty centimeters. So, again, it depends on the size of the patient and the amount of weight loss that we want to achieve. But the bigger this root limb we create, the longer it s going to the bigger is going to be the amount of the risk of nutritional deficiency. 00:07:24 BLANDINE LAFERRERE MD: Right, right. So for this particular patient you re planning to do what what size of the limb? 00:07:30 JULIO TEIXEIRA MD: For this patient, because her BMI is only forty, we re going to do about a hundred centimeter bypass. So it s going to be a minimize the amount of her normal nutrition here. And, also 00:07:44 BLANDINE LAFERRERE MD: But then she ll have a quick weigh loss at the same time, right? 00:07:47 JULIO TEIXEIRA MD: Exactly. So And the next step here that we re going to do is really create what we call an anastomosis, or the connection between the intestines and the We have the Since we divide the intestines, we re going to need to put them together at some point, and this is the place where we choose to put them together so that s going to be our next stop. Again, this is all done in preparation to doing our actual procedure, which is going to be the gastric bypass, you see. So there s a lot that needs to be done before we actually 00:08:28 BLANDINE LAFERRERE MD: And all of that is, of course, the laparoscopy cleaning, right? Where you What we see on the screen is what s the camera eyes at the end of the of the scope, right? 00:08:36 JULIO TEIXEIRA MD: Exactly. This is all being done through a laparoscopic image. Exactly. So, again, this is What we re doing at this point is putting together the intestines into, again, creating a connection between the intestines here. And this is done, again, using staples. There are a variety of different ways of doing this. Our preference is to use staples because it s very safe and easy to reproduce at this point. And, again, the connection has already been created. And now we re going to the next, which is really to close the defect that we have here. 00:10:12 BLANDINE LAFERRERE MD: Okay. So what I would like to do is backup a little bit here and get away from the OR. and just give a basic definition of the Body Mass Index. And the slide I have here, I don t know if it comes up on the Internet yet, it defines what the BMI is. It s the ratio of the weight in kilogram divided by the height in meters square. And this is, I would say, the most important measure in clinical practice to define normal weight, which is a Body Mass Index of twenty to twentyfive. Overweight, which is a Body Mass Index of twenty-five to thirty. Obesity, which is a Body Mass Index over thirty. And then what we call morbid obesity at which point we can offer bariatric surgery, which is a BMI of thirty-five with comorbidities, or a BMI of forty and over. 00:11:08 And so I also want to point out that go back to the slide here that shows the relationship between the Body Mass Index and mortality. There s a direct Page 3 of 17

4 relationship between how much we weigh and the mortality risk. I don t know if the slide will come up on the screen well. It shows on the X Axis the Body Mass Index and on the Y Axis is the mortality ratio. And I m going to pass on the lower end of the curve here for the interest of time, but you can see that at a BMI of twenty-five, which is not the BMI of the condition of obesity, there is already an [inflection?] of the curve and an increased risk of mortality. And, of course, this is much greater in the high BMIs. 00:11:59 Now, I would like to point out also that just like the patient who is now in the OR, most patients with obesity have associated conditions. Diabetes, hypertension hyperlipidemia, all of that is part of what s called the metabolic syndrome and can lead to cardiovascular complications. Respiratory disease and possibly asthma. Sleep apnea, which is very debilitating. Arthritis, especially in knee pain. Depression, urinary tract incontinence and infertility and menstrual irregularity for women. 00:12:40 JULIO TEIXEIRA MD: Thinking of this patient, Blandine, that s an important point. This patient actually has that issue of infertility and menstrual irregularity. It s something that it probably will solve, or we hope to solve in this patient. The other thing there to keep in mind is the fact that surgery is really not a first option always in these patients, but a last resort. And we always reserve it once all other methods of weight loss have failed before we consider surgery as an option. 00:13:10 BLANDINE LAFERRERE MD: Absolutely. Absolutely, I do agree on that. However, I think on a certain level of body weight, when the BMI starts to be, you know, over thirty-five or forty, it is important to offer to that option to the patient as well, even if it s down the line. But definitely medical treatment, diet, increased physical activity, sometimes weight loss medication have to be offered first. 00:13:34 JULIO TEIXEIRA MD: Okay. So Blandine, I want to show you here, if you can come back to the operating room for a little bit. 00:13:39 BLANDINE LAFERRERE MD: Yes, we are. Right. Sure. 00:13:40 JULIO TEIXEIRA MD: Is that we ve actually taken a little bit of time here to close these spaces here between the two pieces of intestines here. And it is so important to close these spaces very carefully because they are actually can potentially pieces of intestine could become trapped otherwise in these spaces. So we ve taken our time, as you see, to close these spaces very carefully in order to avoid that such things occur. Those things are called internal hernias and they can be causes of intestinal blockages, and so on. We can go back to your slide presentation now. I ll bring you back in a few minutes, once we have made a little bit more progress. 00:14:21 BLANDINE LAFERRERE MD: Okay, sure. Well, to go back to who should have the surgery, I think it s indeed very important to keep the surgery as a last resort. And that people have to attempt, you know, weight loss, or nutrition or medical therapy first. 00:14:40 The process of getting the bariatric surgery is fairly complex and cumbersome for the patients. They have to have orientation seminars, which is are very important to understand what s going to happen. And I think there is a lot of emphasis now by surgeons and surgical teams to educate the patient, which is wonderful. They need a complete evaluation by the surgeon, nutritional and psychological evaluation. They Page 4 of 17

5 have to have a letter of support by the primary care physician or the physician who is referring them to the surgery and they need to demonstrate six months of constant losing weight recorded in the primary care office or the nutritionist s office. This is actually an insurance company requirement. The tests are routine tests. A blood test. A ultrasound; I believe it s to look for gallstones. And sometimes endoscopy to assess if there is a chance of a gastric ulcer. 00:15:38 JULIO TEIXEIRA MD: Okay, Blandine, if you want me to just show you something. Remember that window we had created? We have now placed our root limb through that window. We can let go of the stomach now and we can see that that s the window to reach the intestine. It makes it all the way up to the stomach. And I ll bring you back in a few minutes once we get up to begin our gastric dissection. 00:16:00 BLANDINE LAFERRERE MD: The stomach, okay. Well, maybe what I ll do, I ll quickly go to the different type of surgeries and I ll start with the gastric bypass, which is the surgery we have we are seeing today. It s called Roux-en-Y Gastric Bypass. And if you can bring up the slide, it s a surgery that combines a restriction of the stomach pouch. And Doctor Teixeira will explain that to us. And a shunting of part of the proximal intestine where most of the absorption occurs. 00:16:37 It s the bariatric surgery is the most frequently performed in the United States. It s done laparoscopically now since 1993 and it s a really efficient result in about fifty percent of excess body weight loss fourteen years follow-up. This is a little drawing that shows that cartoon that the this is the esophagus and it goes into the stomach pouch. That s anastomosed here to the limb and the gastric juice can still go down here and reconnect so there is no problem. Now the basic facts about laparogastric bypass, it s about a one hour to two hour surgery, very short hospital stay, two days. About seven to ten days of recovery. A regular diet can be resumed about a month after the surgery, although, we ll come back to that. 00:17:34 And then follow-up one week, one month, three month, six month and then every six months for two years. I would like to add to the slide that the follow-up is a lifetime follow-up, of course, even with the surgeon or with the primary care physician or with a specialist in bariatric surgery, especially to assess for potential malnutrition, vitamin deficiencies, an adequate level in the blood of most of the vitamins. 00:18:02 The benefits to expect from the surgery, it s a very rapid weight loss, about twenty to thirty pounds in the first month and up to a hundred pounds in the first six months to a year. At two years, about seventy-five percent of the excess weight loss is lost. The gastric bypass is a combination, as I was saying, of restrictive and malabsorption with [unintelligible] morbidity and mortality. There s a few problems that I m sure Doctor Teixeira will go over, some leaks and strictures. And do you want to show us where you are, Julio? 00:18:40 JULIO TEIXEIRA MD: Yeah. I think it s important to realize that those points that you are making are very important. Although these operations are extremely successful, it s very important to keep in mind that in fact these are very serious operations that are being performed. Although we re performing hundreds of thousands of them annually in the United States today, there is still a complication rate that is quite significant and there is still a complication and a mortality rate; the patients can certainly die from this procedure. 00:19:08 Page 5 of 17

6 The most common reason why patients can die from this procedure include things such as, you know, myocardial infarction or heart attacks. Obviously, patients that are obese have a significant risk of cardiovascular disease, as you know. And, certainly, we will be doing testing to make sure that we re doing the surgery in the safest environment as possible. But, certainly, it s still, particularly diabetics are at risk for what we ll call acute heart disease. So certainly 00:19:37 BLANDINE LAFERRERE MD: Right. That would be true for any kind of surgery though. 00:19:41 JULIO TEIXEIRA MD: Right. Other problems that can lead to mortality include things like like pulmonary emboli. Certainly, again, patients that are obese have a higher risk of formatting of blood clots, and so on, so we try to take all the preventions possible to avoid that, but certainly there s a risk of that. Other complications like intestinal obstruction can lead to mortality. Overwhelming infection when it s associated with leaks. And I ll talk a little bit more about that once we get up to doing our our gastric anastomoses, or during the connection to the Again, if you re looking at the image right now, what we re just doing right now is nothing but prevention. This is nothing but What we re doing is steps that we re taking to avoid complications. Again, there s a potential problem which can occur at this particular position here. We ll just call it an internal hernia. 00:20:34 At the Peterson space, as you can see, this over here is Peterson space. So we re taking time here to simply make sure that this space is properly closed so that as the patient losses weight this is not an issue. So, again, we re taking our time here. We re not doing any specific steps that truly are part of the effective operation, but these are truly simply preventive steps to avoid complications. Again, safety is our number one concern in this procedure. We want to make sure that patients lose weight and that their medical problems are addressed, which is obesity and diabetes, and their high blood pressure and the cholesterol. But we also want to make sure that they actually are go through a very safe operation with minimal risk of complications. So, again, we spend a significant amount of time in this operation; really, all we re doing is we re doing the steps here to prevent the actual potential complications that can occur. 00:21:42 Again, we expect this patient that perhaps within the next month that she will be completely off all her diabetic medications and she will be completely off, potentially in the next two or three months, her antihypertensive medications. And then, hopefully, in the next six months that she will not be needing any other medication other than her nutritional supplements, like iron and vitamins, which anybody that undergoes this operation would need to have. I m sure, Blandine, you ve had some experience with your diabetic patients who have shown significant improvement after this operation. 00:22:16 BLANDINE LAFERRERE MD: Absolutely. Absolutely. Diabetes is a condition directly linked to obesity. There s about eighty percent of patients with Type II diabetes who have obesity. And you ve seen on the previous slide that I ve shown that about thirty percent of patients presenting for bariatric surgery have Type II diabetes. And, actually, some times that up to a third of those patients do not know that they have Type II diabetes. So it s a very prevalent condition. And the link with obesity is extremely important. 00:22:51 Page 6 of 17

7 So what s happening after gastric bypass surgery is a few things. The number one, there is very rapid weight loss, and it is true that any kind of weight loss improves Type II diabetes. There is also, of course, a reduction of food intake and calorie intake, which also improve the Type II diabetes. But there s also something that might be directly specific to the procedure, because the diabetes tends to get better within days after the surgery, which is very unusual and independently of significant weight loss. It might be some peptides in the gut or in the stomach, some hormones that are important in that type of relation, you know, in some [secretion?] that are going to be involved. And active active research is going on, on this. But patients with Type II diabetes can expect the diabetes to surely get better. Most of them will be off their medications. 00:23:49 There is However, the situation of diabetes is a really important factor. If it s a recent onset diabetes, it s been diagnosed within five years, the literature shows that there is a about or, close to ninety percent chance of cure of the Type II diabetes or full resolution without medication, full control. If the diagnosis has been there for over ten years, fifty years, twenty years already, it s unlikely that it will entirely go away. But, surely, the treatment will be much easier, the diabetes will be very easy to control with less medication and surgery is still a major improvement. 00:24:29 I want to point out the slide here of resolution of co-morbidities. And there is many, many papers and literature confirming that, including the [this analysis?] published in JAMA a couple of years ago, that in between seventy-five to ninety-five percent of cases most of the co-morbidity is resolved with bariatric surgery. Type II diabetes, we just talked about it, hyperlipidemia, high cholesterol, high triglycerides, hypertension, cardiac function. And if you look at the bottom of the slide here, there is three complications: Urinary incontinence, sleep apnea and osteoarthritis. And the symptoms linked to those complications improve. Meaning the quality of life of the patient improves. The urinary incontinence disappears. The fatigue and the poor sleep linked to the sleep apnea improves. 00:25:25 JULIO TEIXEIRA MD: Blandine? If you want to come back here for a minute. 00:25:27 BLANDINE LAFERRERE MD: Sure. No problem. 00:25:29 JULIO TEIXEIRA MD: I just want to show you. We re going to about get ready with our dissection of the stomach and just wanted to show the anatomy. The stomach begin right here. This is where the esophagus ends. We can see it on the other side there, that s the spleen. 00:25:38 BLANDINE LAFERRERE MD: So [you know?] the diaphragm here, can you see the diaphragm here, or? 00:2540 JULIO TEIXEIRA MD: Yeah, the diaphragm is up here. Okay, and that s the liver. We have a very large liver. The esophagus is here. This is the stomach. You can pull the camera back and we ve got a nice broad view of the stomach. 00:25:54 BLANDINE LAFERRERE MD: Oh, I see. Right. 00:25:55 JULIO TEIXEIRA MD: Okay, a very large stomach. And so we re gonna come here now and begin the dissection. We re going to create a very narrow stomach, which is gonna be about five centimeters in length, at most. So, this is where we re gonna begin our dissection. Then we re going to create a very small stomach. Why don t Page 7 of 17

8 you go back to your talk and I ll bring you back in a few minutes, once we have this dissection begun. 00:26:17 BLANDINE LAFERRERE MD: Okay. Okay, very good. Okay. I just want to remind the audience also that if they need to ask any question they can click the button. I believe there s the MD question button on your screen. And [those who?] any questions to us, we ll try to address them during this live broadcast. 00:26:33 So I was talking about resolution of complications and improvement of quality of life in the in the case of osteoarthritis. It s essentially the pain leading to the osteoarthritis, especially in the lower extremities like a knee pain that gets better after the weight loss due to the surgery. So this is very very important. 00:26:54 And when the decision to chose the surgery versus another treatment, like medical, diet or exercise come into the picture. When you can offer your patient in about eighty percent of cases a resolution of complication, I think it s nice to have this this tool. I want to yeah? 00:27:18 JULIO TEIXEIRA MD: Okay, if you want to take a look, what we re doing now we re just dissecting around the stomach. And what we re doing is we are trying to get into the posterior aspect of the stomach, or the back wall of the stomach, so we are able to actually divide the stomach. So there are a lot of little blood vessels in this area, so we re taking our time in doing this dissection in order to avoid any bleeding. Again, any bleeding in this area, it tends to be very minimal in character. It may appear big on the screen. Again, keep in mind that that there is a twenty power magnification here, so what may appear to be bleeding is really very, very minimal amounts of bleeding at all. 00:28:04 BLANDINE LAFERRERE MD: Well, actually, there is no bleeding at all here. I have to say, it s the first surgery I ve seen where there s no blood at all. That s great. Yeah. It s amazing. 00:28:11 JULIO TEIXEIRA MD: So we re now actually going to begin dividing the stomach. This is a stapler that we use to begin to divide the stomach. So we re going to make a, again, a narrow stomach. So we do wait a few seconds here to make sure we have complete compression of the tissues and that good staple formation, again, to avoid bleeding. So I take my time here and I have everyone look at the clock and tell me when it s ten seconds before I actually begin to divide the stomach. So And now I m going to have the anesthesiologist advance a [bujia?], which is going to give us a sense of of pouch size. Again, we want our pouch to be very small. We re going to create a pouch that is approximately about thirty CC s, so it s about the size of an ounce, about the size of a shot glass. Approximately the size of a golf ball, just to give a sense of proportion. And so 00:29:14 BLANDINE LAFERRERE MD: What happens to this pouch over time, Julio? 00:29:17 JULIO TEIXEIRA MD: With time, we do expect it to grow somewhat, and the patient can have a normal life within the next two years. The idea is that in the beginning, particularly, it will create a very restrictive pouch. So the ability to eat initially is very small. So, we will initially create a pouch that is about thirty CC s. And this one Again, you can see that [bujia?] coming in at this point here. So And you can see the pancreas underneath. So the idea is that in meals initially, the first week they will be simply on liquids. Okay? Plus a protein supplement. After that, within Page 8 of 17

9 the next week they ll start puree meals. Approximately, again, their meals will be the size of about two to three ounces. 00:30:08 BLANDINE LAFERRERE MD: Right. So there will be multiple, very small meals and snacks, and basically sipping on small quantities, right. 00:30:15 JULIO TEIXEIRA MD: Exactly. 00:30:16 BLANDINE LAFERRERE MD: It s important to keep the hydration, yeah, just after the surgery. 00:30:19 JULIO TEIXEIRA MD: Exactly. So And, usually, somewhere around, you know, a year from now we expect that their meals will be approximately about two to three about the size of the palm of a patient s hand, approximately, to give you a an idea. So, again, it s a major component of the weight loss is the fact that they have such a restricted diet. The other component is, obviously, the malabsorption and that we talked about in the beginning, because we re bypassing a part of the intestine, which you will see in a few minutes as we ll be finishing the division of the stomach here. And we are almost there. Again, you can see the difference between the two stomachs. That s the new stomach and that s the old stomach, which is quite large. And the new stomach is going to be approximately about, I think about, about the size of your thumb. 00:31:11 BLANDINE LAFERRERE MD: Wow! Okay. 00:31:12 JULIO TEIXEIRA MD: So quite small. So, if you want to go back to your talk for a few minutes, we re going to finish the division of the stomach here. And I ll show you the final part in a few minutes. 00:31:26 BLANDINE LAFERRERE MD: Great, great. Any questions from the audience, again, let us know and feel free to interrupt at any time. I just want to talk a little bit about we talked about the nice things, which was that all most complications disappearing, some of the treatment, patients being able to stop their medications and most of those conditions, like Type II diabetes, hypertension, hyperlipidemia, require sometimes up to five medications per condition to control that efficiently. So it s a it s really a relief for the patients to be able to stop those medications. 00:32:01 However, I want to point out that there will be a need for vitamins and calcium supplementation and for long term and potentially lifetime. And that s really important. Sometimes misunderstanding, the patients feel that just they need to take the vitamins for a few weeks or a few months; this is not the case. It s really a very long term process and sometimes a high dose of vitamins because, remember, the absorption is decreased so may have to ingest, you know, high dose of Vitamin D, Vitamin B-12 to make sure that there s adequate supplementation. 00:32:44 JULIO TEIXEIRA MD: All right, Blandine, if you want to come back I m going to show you. This is the last stapler to the completely divided stomach. Come back with the camera please. And you can see the stomach has now been completely divided into two parts. Okay? Completely divided. So this is the new stomach, okay? And this is the, again, old stomach that will never see food again. People often ask what happens to it, it kind of leads a boring life from now on, essentially. But nothing dramatic. It doesn t die or rot away. 00:33:19 Page 9 of 17

10 BLANDINE LAFERRERE MD: Well, it still secretes the gastric juice, right? And it s 00:33:23 JULIO TEIXEIRA MD: Yes. 00:33:24 BLANDINE LAFERRERE MD: Right. 00:33:25 JULIO TEIXEIRA MD: And those are important for digestion, you know? It will be used [unintelligible] later on. So, go ahead. I ll bring you back in a few more minutes as we begin our next [ones?]. 00:33:34 BLANDINE LAFERRERE MD: Okay. Well, we do we do have a few questions here. Some of them, actually, you might be more qualified to answer than me. 00:33:41 JULIO TEIXEIRA MD: Okay, go ahead. You can ask me. 00:33:42 BLANDINE LAFERRERE MD: Right. The first question is, is the surgery difficult due to the layers of fat that you must get through in order to reach the stomach? 00:33:50 JULIO TEIXEIRA MD: Well, certainly there is some level of difficulty in performing laparoscopic surgery, particularly on the obese. And initially, when first I was doing laparoscopy, there was a concern whether or not it was safe or even possible to do it on patients that were obese. Certainly, also, obese patients are the ones who stood to benefit the most from a laparoscopic procedure. And, certainly there s some level of difficulty, but it is certainly worthwhile to the patient. One of the sayings that I often like to quote is that the night after laparoscopic surgery the patient always looks better than the surgeon. And that s because we re really working very hard to try to bring significant benefits to the patient by avoiding a large incision. 00:34:44 So what we re doing now is we re going to establish now a connection between this new stomach and the old stomach and I m sorry, the small intestine, to allow food to go directly from this new stomach directly into the small intestine. In other words, bypassing the rest of your the big stomach, you see? So that s the next step. And there s a variety of different ways of creating this anastomosis. So what we re going to do is a completely hand sewn anastomosis here, which is rather than using stapling machines to accomplish this connection, we re going to do it completely by a hand sewn technique. And reasons why we like to do that is because I believe it brings it gives me the ability to fashion this anastomosis to whatever size I want, to any place in the intestines, on the stomach, that I like. It gives me a lot of freedom. And, also, it s a very safe way of doing the operation. I believe it increases safety, and so those the leak rates, our complication rates regarding to the connection is a lot less. 00:36:00 BLANDINE LAFERRERE MD: Okay, okay. Well, that s nice to hear. There s another question here. I m going to try to answer it, but maybe you can comment as well. Is there any age group that tolerates the surgery best for the necessary recovery time and as people return to normal activities? And I believe the surgery, the age group is generally between eighteen and up to seventy years of age. Although, there is - Although surgery performed in an adolescent, and I believe the believe the Australians have the most experience with that. Would you comment on that, Julio? 00:36:32 JULIO TEIXEIRA MD: Certainly, we do not have a lot of studies out there look to know whether or not these operations are safe on the adolescent, or whether or not they are successful and effective on the adolescent. There are centers out there Page 10 of 17

11 performing it, but anyone considering it should realize that it is still an experimental procedure in that particular age group. These patients who are very young are still undergoing growth and development, both physical as well as psychological. And so the idea of performing such a dramatic, drastic procedure that s life changing, and irreversible, is important 00:37:12 BLANDINE LAFERRERE MD: Irreversible, right. They left a new question about the reversibility. The gastric bypass is important, but it is not a reversible procedure, right? 00:37:20 JULIO TEIXEIRA MD: Yeah. Theoretically it is, but anyone considering it should keep in mind that we are that reversing it is a bigger operation than what we re doing right now. And so if you re considering this operation, you should take it as an irreversible operation. Certainly, in the case of an emergency where a reversal may be required, we can do it, but it s not something to be considered when 00:37:45 BLANDINE LAFERRERE MD: It s not really a Right, a routine option. So maybe we can talk a little bit about gastric banding. There s a question about how does the gastric bypass compare to the lap band. And I have a few slides of the on the lap band here that I m going to show. This first slide here show the device. The lap band is consists of a little ring that s inflatable, connected to a port under the skin. So the ring goes around the stomach and is adjusted for the port. So it s purely a restrictive procedure and absolutely noninvasive. There s no cutting or pasting, like we re just seeing on the screen right now. And it brings pretty good results as well, long term. I think the Europeans and the Australians have the most experience with that. And we were just talking about surgery in teenagers and I think that s the preferred technique of surgery in younger groups. 00:38:48 JULIO TEIXEIRA MD: Certainly, I agree. I think if the younger population should benefit from the fact that it s less invasive, as well as a reversible procedure. And the same thing can be said about the older patient population, where there may be a higher risk of [post?] operative complications. So that patient can also benefit from a minimum invasive procedure. 00:39:13 BLANDINE LAFERRERE MD: Absolutely. Right. That s actually true of most surgery. I mean, the older and the more co-morbidities associated with the patient, the higher the risk of any kind of surgery. 00:39:27 There is a surgery about this a question about this particular patient, Julio. Did you ask the patient to lose weight prior to the surgery and are you going to remove her gallbladder? 00:39:38 JULIO TEIXEIRA MD: Oh, okay. That s a great question. We do ask patients to lose weight if we find a reason to do so. We do not like to necessarily just punish patients just in order to be able to but, certainly, preoperative weight loss is an indication it s a good indication of success postoperatively. And there s certain reasons why we often require patients to lose weight, particularly if they have a cognitive issue, a psychotherapeutic issue that we keep in mind. If there is an issue regarding any medical problems, such as a pulmonary problem that losing weight may improve their risk of anesthesia. 00:40:26 BLANDINE LAFERRERE MD: Right. Exactly. Their condition. Right. 00:40:27 Page 11 of 17

12 JULIO TEIXEIRA MD: So there are certainly good reasons why we often require patients to lose weight. But, also, in regard to the gallbladder, again, in the past that used to be considered a routine part of this operation, because often these patients who have obesity have gallstones. And other patients who do not have, will form gallstones. 00:40:50 BLANDINE LAFERRERE MD: Right. After their record weight loss. 00:40:51 BLANDINE LAFERRERE MD: So the chances because of rapid weight loss, exactly. So there is a potential for them to develop symptomatic gallbladder disease. And if that happens, they may benefit from gallbladder surgery. Now in the past, they used to do it routinely because doing a gallbladder surgery after gastric bypass was quite a challenge, because of the scar tissue and so on. And now 00:41:18 BLANDINE LAFERRERE MD: Because it was open Because it was open surgery, right? 00:41:20 JULIO TEIXEIRA MD: Because there was open surgery. Now today, we really don t have those same issues because we cause very minimal scarring after a minimally invasive gastric bypass. So, really, the issues regarding the risks of gallbladder surgery afterwards no longer are warranted. The other concern is that, you know, whenever you do added surgery there is always potential for risk for complications too. So we want to avoid those types of complications, if the patient doesn t really need surgery. 00:41:57 So we actually did a study looking at our patients and at the end of two years what we found is that only about seven percent of our patients really developed symptomatic gallstones, so it was a small number. Although a lot of them developed gallstones, but very few had symptoms from it. And when we looked at those did have symptoms, most of them did not have gallstones before the surgery. So we found the presence of gallstones on preoperative ultrasound itself was not a good indicator. So we only do gallbladder surgery in patients that may have gallstones and symptoms from their gallstones. So if, perhaps, there s attacks from their gallbladder, so in that case we will perform gallbladder surgery. 00:42:46 BLANDINE LAFERRERE MD: Um hmm. At the same time. Okay. There s a question here that asks if it s common for a patient to experience nausea right after they wake up from surgery? I don t know if you want to take that as well. It s not It s not been reported by any of my patients right after the surgery when they wake up, but I maybe it s because I m not there when they report it. Do you have any experience with that? 00:43:10 JULIO TEIXEIRA MD: It s not uncommon that patients can experience some nausea. And literally every single patient that undergoes this operation will have some nausea, vomiting at some point, you know. 00:43:21 BLANDINE LAFERRERE MD: But not necessarily just when they wake up from the surgery. 00:43:23 JULIO TEIXEIRA MD: Not necessarily just when they wake up. In fact, it s uncommon because we actually will take steps with our anesthesiologist to to give medications and pain medications to prevent nausea immediately post-op. But, again, all patients that undergo the surgery will experience some degree of nausea, Page 12 of 17

13 vomiting. But usually it s not a debilitating experience. Again, part of this operation is the adjustment process that patients will go through. And that adjustment process is quite it s quite difficult and so they re going to be having a learning process over the years as they adapt to their new anatomy. And that process will often lead to some nausea, vomiting as they try new foods and they begin to adapt to this, again, this new anatomy. 00:44:17 BLANDINE LAFERRERE MD: Right, right. There s also a complication here I want to go back to, a slide here, if you don t mind, of gastric bypass, but the problems leading to gastric bypass. So there s a few percentage of leaks, I guess that s during the where you make some sutures. There s some strictures also, complication in a very small percentage of cases. 00:44:40 JULIO TEIXEIRA MD: Yes. Again Again, what we re doing right now is creating that anastomosis. And the thing here that s of concern is that as we re creating this anastomosis whether or not it s well sealed all the way around before we before we begin to feed the patient. And if it isn t, potentially as this patient eats, it could potentially leak around and lead to a terrible infection could occur. 00:45:11 BLANDINE LAFERRERE MD: Right. Correct. 00:45:12 JULIO TEIXEIRA MD: Or the leak could be is actually this connection was not well sealed at the end of this operation once the patient begins to eat.. Now leak rates nationwide vary approximately between twenty-five and two percent. 00:45:29 BLANDINE LAFERRERE MD: And two percent, right? Yeah. It s a very small percentage. Right. 00:45:30 JULIO TEIXEIRA MD: Now, our leak rates are extremely low. And our ICU utilization is also extremely low. In fact, I would say over the last year we have not had a single patient in the ICU. 00:45:48 BLANDINE LAFERRERE MD: Well, that s wonderful. Wonderful. Now there s another complication of gastric bypass that has a little bit to do with quality of life, so I just wanted to point that out. It s called dumping syndrome and that at times can be debilitating, but also some patients actually do not necessarily experience it. Dumping syndrome is a combination of symptoms, such as stomach or intestinal cramp, some diarrhea, some flushing, some fainting at times and some nausea and vomiting on occasion. And very often that s repeated with the ingestion of certain types of food and possibly with sweet beverages. 00:46:34 JULIO TEIXEIRA MD: Yes, absolutely. Dumping is fairly or it can be debilitating. It s uncommon though that we see such debilitating dumping. We see dumping in about ten percent of patients and 00:46:48 BLANDINE LAFERRERE MD: And usually they adjust the diet in order to avoid the food that gives them some the worst symptoms. 00:46:57 JULIO TEIXEIRA MD: Yeah. Usually it s very Well, in fact, we like dumping to some degree, because patients really stay away from those foods that they 00:47:05 BLANDINE LAFERRERE MD: Right. From the sweet beverages that are detrimental to their health anyway. Page 13 of 17

14 00:47:10 JULIO TEIXEIRA MD: Exactly. So, again, we re sort of sewing our way around this connection. 00:47:18 BLANDINE LAFERRERE MD: Now we did get a pretty technical question. I don t know if you want to address that. It looks like it might be even by a surgeon or a physician. I notice that Doctor Teixeira took one bite with the stapler laterally and then angled it superiorly from the rest of the dissection of the stomach. It seems easier to me to dissect straight across the fundas. What is the reason for the pattern of the dissection of Doctor Teixeira chose to perform? 00:47:43 JULIO TEIXEIRA MD: That s a great question. That s obviously That s obviously coming in from a very technical That s a great question. The reason why I do that is because I want my pouch to be along the lesser curvature of the stomach. And the reason why I want to do that is because I want to create a narrow pouch. And the reason why I use less curvature is because it s an area that has less amount of elastic fiber, so the chance that my pouch to dilate over time is very little. So the reason is to prevent for growth and dilation of my pouch in the future. And so that s the reason. So I create a narrow columnar pouch along the lesser curvature of the stomach. Does that answer the question? I hope it did. 00:48:29 BLANDINE LAFERRERE MD: I m sure you did. Surely I was not able to answer this one. So I want also to point out you did mention that this patient had some irregular menstruation and I do see in my practice very frequently that women have infertility problem in relation to their obesity. And we have a slide here regarding pregnancy after bariatric surgery. And there is no restriction of time after the lap band surgery to start a pregnancy. After gastric bypass, however, I believe the surgeon I would prefer that the patients wait about two years to start a pregnancy. Do you want to comment on this two year lag time, Julio, or is that not a good time for you? 00:49:15 JULIO TEIXEIRA MD: Yeah, actually, if you want to come back to the image once second and I ll show you what we re doing. What we re doing now is actually advance the [bujia?] please. And we re going to advance our [bujia?] past our anastomosis, because we want to guarantee that we have a passage that s [patent?]. And we also want to guarantee our size to be very narrow. Again, size of the connection is very important in order to achieve long term weight loss. So, pull up on it please. 00:49:42 Now, so regarding you question, absolutely. I think it s important to realize that all patients after this operation can have children and conceive safely. The reason why we like to wait two years is to avoid that these patients have any high risk for birth defects, particularly as they re going through rapid weight loss and their diet may not be adequate to sustain a normal pregnancy. After that they should be able to, in fact, healthier children. First of all, we find we treat infertility in a lot of our patients. Secondly, the risk of birth defects goes down with weight loss. So the only thing is that in the first two years it should be avoided. Now, certainly, with a lap band that s not necessarily an issue. So that s certainly one 00:50:35 BLANDINE LAFERRERE MD: Right. I guess with the lap band, the tightness of the band can be adjusted during the pregnancy. 00:50:41 JULIO TEIXEIRA MD: Exactly. And with appropriate nutritional counseling, appropriate with appropriate guidance from their gynecologist they should do fine. Page 14 of 17

15 00:50:54 BLANDINE LAFERRERE MD: Very good. 00:50:55 JULIO TEIXEIRA MD: Again, see, we re coming out to the end now of our connection, which has been established here. We re seeing, again, that we have guarantee of a patency with our [bujia?] place. 00:51:07 BLANDINE LAFERRERE MD: So the [Bujia?] is about the size of a finger, or? 00:51:10 JULIO TEIXEIRA MD: It s about a centimeter in size. So our connection is going to be a centimeter. So that is the nature of our anastomosis. 00:51:22 BLANDINE LAFERRERE MD: There s also a question here about preparation before the surgery. Someone is asking if they you need a pre-op bowel cleansing or if a clear liquid suffices? 00:51:34 JULIO TEIXEIRA MD: I believe a clear liquid diet suffices. So we don t We used to do bowel cleansing in the past. We no longer do that. We find that simply keeping a patient on a clear liquid diet may be adequate enough to do so. So, again, we are not yet at the end, but we re almost getting there. We re going to be putting one more layer of sutures here just to increase our safety. Again, my number one concern in this operation is safety. So we want to make sure that this In fact, our patient here will not be getting an upper GI series tomorrow. Again, one thing that a lot of surgeons will do is do an x-ray tomorrow on this patient to make sure that any potential risk for a leak has been ruled out by a special x-ray tomorrow. We will not be doing that. This patient will get up tomorrow morning and start on a liquid diet. And that is will be a part And, again, by the second day after the surgery, so expect by Wednesday morning she should be on her way home. 00:52:56 Again, the only thing she ll have is essentially a Foley catheter to measure urine output. She ll have a patient [unintelligible], a little button that she can press to give herself pain medication and the only other issue that she ll have is an IV for IV fluids, which by tomorrow afternoon when she reaches her little goal and turns off her preoperative or in terms of her diet, she should be off her IV fluids tomorrow. And she should be on pain pills by tomorrow evening. 00:53:37 BLANDINE LAFERRERE MD: Okay. So I just want also to point out a little bit, because there was one question about what happened to the excess skin. We actually had one slide to go over that. And what we do recommend is to wait about two years after the gastric bypass surgery for weight stabilization and weight maintenance before contemplating any plastic surgery. The weight has to be stable before doing this the plastic reconstruction, if needed, of the excess skin. And there should be absolutely no evidence of malnutrition, so the vitamin levels have to be checked and adjusted. This actually might not be necessary for all patients, and different factors can impact that. 00:54:25 JULIO TEIXEIRA MD: Exactly. Some patients are comfortable with the way they feel, they look after surgery. But it s important to realize that it s not just the skin that needs to be addressed. But most importantly is the mind of the patient needs to be addressed. We have well established seminars and support group systems that are key to long term success. Again, these operations work not because of what we ve done, necessarily, but mostly because it s going to cause significant behavioral modification. Essentially we re going to have our patients, hopefully, will develop Page 15 of 17