Info for Medical Practitioners

Dear Colleague,

Thank you for taking the time to visit my website. The following information aims to affirm my Peak performance protocols and answer common questions about my bariatric services. I will be using this page to explain my personal surgical care philosophies and offer insights into my professional ethical standards.

Please don’t hesitate to contact me with questions or feedback at any time.

Sincerely,

Dr. Candice Silverman
MBBS (hons) FRACS

Why is the Peak Program Unique?

The concept behind the Peak Program is that it is an individualized, personalized and boutique service.Patient seminars are not performed, each patient has their own individual assessment with the surgeon who will discuss and arrange appropriate weight management strategies. A close relationship and communication is maintained with the patients General Practitioner or Physician.

Why bariatric surgery?

Obesity is a chronic disease. Obesity surgery has a greater efficacy then conservative measures (diet, exercise, drugs) in helping morbidly obese patients loose and maintain weight loss.Surgery is performed to help patients live longer and to improve quality of life. Obesity surgery is not a stand alone procedure. Surgery will help the patient lose weight but there is a “two way street” in terms of patients maintaining this weight loss.The patient needs to make behavioural changes that will outlast the effect of the operation to avoid weight regain, and also to maximize the weight loss result from the operation. Hence, the requirement for participation in follow-up sessions and giving patients access to tools and the support of a multidisciplinary team (specialised dietician, exercise physiologist and psychologists).

What operations do I offer?

Laparoscopic Sleeve Gastrectomy            (LAGB)Laparoscopic Adjustable Gastric Banding (SG)Laparoscopic Roux en Y Gastric Bypass (RYGB)Intra-gastric Balloon Placement (IGB)

What are the NHMRC Recommendations for Weight Loss Surgery?

BMI>35kg/m2 with obesity related health conditionsorBMI>40kg/m2

What factors need to be considered prior to surgery?

Considerations – Blood testingInitial Metabolic Screen is performed if not already done by GPFBC, UEC, Mg, Ca, PO4, LFTs,  Lipids, Glucose, HBA1C, Folate, Vit B1, Vit B 12,  Vit D, Homocysteine, TSHRepeat Blood testing (without Homocysteine and TSH testing if normal ) is done annually for SG and LAGB patients and 6 monthly for RYGB patientsConsiderations – AgeFor age <18 years – Referral to our multidisciplinary team is made , surgery is not offered for adolescents in this clinic, referral to an adolescent obesity service would be ideal but currently this service does not exist.

For age >65 years – Discussion of the risk vs benefit relationship between surgery and living with obesity. Surgery won’t necessarily influence longevity though it can improve mobility and quality of life. Discussion of positive effects of weight in improving bone mineral density and decreasing chance of osteoporotic fractures.

Considerations –  Abdominal Wall

For the morbidly obese with abdominal wall hernias, ideally they will undergo assessment for hernia repair 12 months after successful weight loss surgery. Attempting elective repair of hernias when obese is fraught with complications including recurrence and wound infection. Emergency management of these hernias may still be required in the minority and advisement is given to present to the emergency department if signs of hernia complications develop specifically those of strangulation. For those with ventral hernias of the abdominal wall often these can be repaired at the same time as performing an apronectomy/abdominoplasty if there is excess skin.

Considerations – Reflux

Both the LAGB and SG are operations that are in theory pro-reflux. Reflux as a symptom, though, is often related to increased intra-abdominal pressure due to adiposity and in theory this can be reduced with a weight loss operation. For those with significant reflux symptoms the RYGB should be considered as it is an anti-reflux operation. For the first 4 weeks after surgery SG patients are required to take a proton pump inhibitor (eg pantoprazole 40mg daily).

Considerations – Diabetes

The SG and RYGB has an anti-diabetic effect beyond just that seen with weight loss unlike the LAGB which is more a restrictive procedure. For those patients with type 2 diabetes requiring insulin RYGB should be considered as there has been shown to be an increased benefit for this patient group in reducing insulin requirement as compared with the SG.

Considerations –  The Gallbladder

Anyone that is symptomatic from gallstones will have a cholecystectomy performed at the same time as their weight loss procedure. Intra-operative cholangiogram is not routinely done during surgery (especially if done robotically) so if there are any pre-operative indicators of possible choledocholithiasis, pre-operative imaging of the bile duct is obtained (CT cholangiogram or MRCP). Patients are told there is an increased risk of gallstone formation with rapid weight loss as is seen post weight loss surgery.

My approach to revisional surgery?

I believe for patient safety that those who have a gastric band in currently, who have failed to lose weight, any further weight loss surgery should be done in 2 stages. That is, to first remove the lap band (laparoscopically), wait a minimum of 3 months, then proceed with the second operation. This is done for safety to reduce the risk of leakage from the staple line.  Some would consider the RYGB the “gold standard” weight loss operation and the safest operation for revisions. There are, however, many large series of revisional sleeve gastrectomies following failed gastric bands. Patient choice is important here though perhaps those requiring surgery following a LAGB removed for an erosion or for those that have had prior vertical banded gastroplasty (stomach stapling) RYGB should be strongly considered.

Bariatric surgery for smokers?

Only non-smokers are offered elective bariatric surgery. This is because smoking is a more significant health risk then carrying excess weight. Also smokers have an increased risk of complications from surgery. Patients need to have had “their last smoke” over 3 months prior to consideration of elective surgery for obesity.

How can alcohol impact on a patient’s success?

As discussed, to achieve success patients must be committed to changing their attitudes and behaviour. This applies not only to what they eat, but also to what they drink. Alcohol is a calorie rich substance with minimal nutritional benefit. It impedes weight loss and my patients need to be willing to minimise their consumption.

Treatment options for low BMI patients?

Consideration for obesity surgery for BMI>30kg/m2 may be made especially if the patient has weight related health conditions. Consideration of temporary weight loss measures which includes the intra-gastric balloon and very low calorie diets. Maybe LAGB may be appropriate for this group as it is a low risk intervention.

What is good weight loss?

Not all weight loss is good weight loss. Patients need to understand the concept of eating “to put fuel in the engine” as opposed to eating for satiety. Maintaining muscle mass is important especially during the initial stages of surgery, this will require adequate protein and micronutrient intake. Patients will need to take multivitamins lifelong (especially gastric bypass patients). Dietician input is extremely important.

When is a gastroscopy performed?

Is performed pre-surgery for gastric bypass patients and for those who are having revisional surgery.

What is the role of Robotic Surgery?

The da Vinci Robot is an amazing piece of technology which allows improved visualization, dexterity and precision for the surgeon which in theory relates to less patient pain and a decreased risk of complications. This is seen especially for operations requiring an anastomosis (RYGB). I feel too those in the super obese category (BMI > 50kg/m2) benefit with less abdominal wall pain following robotic compared with laparoscopic surgery.

How do I audit?

We commit to audit. The Australian Bariatric Surgery Registry which is run by Monash University requires the completion of audit forms at one and 12 months post surgery. A prospective audit of all patients undergoing obesity surgery is maintained in our “lapbase” database. A survey is sent to all patients at 12 months following their weight loss operation so we can improve the quality of our program.

The Peak Program: What can patients expect?

Pre-operative Visits

    1. Assessment for the appropriateness for weight loss surgery is made. The program is explained as are the various weight loss options. Information is given re Obesity surgery and on the specific operation the patient is interested in.  A form for initial blood testing is given (unless already arranged by the GP). Appointments for dietician, and psychologist and for the final pre-operative visits are made.
    2. For the final pre-operative visit the dietican, psychologist input and blood testing is reviewed. The formal consent process for the operation of choice and John Flynn Admission paper work is attended to. The main complications of the various operations are listed below

Sleeve Gastrectomy: Leak from the staple line. Bleeding. Injury to other organs. Wound infection. Narrowing of the gastric tube requiring endoscopic or surgical management. Deep leg vein and portal vein thrombosis. Lung clot (pulmonary embolus). Late complications include reflux and weight regain.  Incisional Hernias. Weight loss can result in gallstone formation and if symptomatic may require cholecystectomy. Excess skin. Death would be an unexpected outcome with death rates <1%.

Laparoscopic adjustable gastric banding: Port site infection. Wound infection. Bleeding. Injury to other organs.  Slippage of the band. Dilatation of the gastric pouch or oesophagus above the band. Deep Leg vein thrombosis. Lung clot (pulmonary embolus). Band erosion/migration. Leakage of saline from the band, tubing or porthole. Failure of weight loss.  Reflux. A requirement for on-going adjustments and consultations life long.  A likelihood to require revisional surgery.  Lifestyle adjustments need to be made with a requirement to chew food well and avoid certain food types such as stringy meats and white bread. Death would be an unexpected outcome with death rates <0.1%.

Gastric Bypass: Anastamotic Leaks (Gastro-jejunostomy or entero-enterostomy). Bleeding. Injury to other organs. Wound infection. Vein thrombosis – deep leg vein and portal vein thrombosis. Lung clot (pulmonary embolus). Dumping syndrome.  Stomal stenosis. Stomal ulceration.  Small bowel obstruction. Incisional hernia. Weight regain. Weight loss can result in gallstone formation and if symptomatic may require cholecystectomy. Excess skin. Death would be an unexpected outcome with death rates <1%.

Length of Hospital Stay

IG – day stay

LAGB – overnight stay

SG – 3 nights

RYGB – 3 nights

Post Procedure Diet

LAGB/SG/RYGB – fluid only diet for 2 weeks, then a gradual transition to a solid diet at the 4 week mark. Under no circumstances should the patients eat solids prior to the 4 week mark. For LAGB patients they should not eat white bread, white pasta or stringy meats at any stage. IGB patiens will be on a fluid only diet for 1 week then on a normal diet there-after.

Post Operative Follow-up

Patient is weighed and all weights are included in the lapbase database.

1 month: Specifically symptoms of reflux and dysphagia are illicited now the patient is on a solid diet. The Obesity registry forms for one month follow-up are completed. LAGB patients receive their first band adjustment and review is required monthly until they are in the “green zone” of restriction.

3/6 month: assessment of patient compliance to diet is made and exercise is highly encouraged – (incidental exercise, cardiovascular activities, and resistance training)

12 month: The obesity registry forms are completed. Assessment of the abdominal wall for consideration of hernia repair if present and abdominoplasty if required.

Regular GP review is required especially if obesity related health conditions are present and a reduction in medications is required (eg blood pressure, diabetes and cholesterol medications).