Steven Leeds, MD, Esophageal and Gastric Surgery, a Minimally Invasive Surgeon or a Gastrointestinal Surgeon at the Baylor University Medical Center in Dallas, Texas talks about bariatric surgery and the surgery sometimes used to fix it if it goes wrong.
Interview conducted by Ivanhoe Broadcast News in April 2018.
By the time you saw Isabel she was in pretty bad shape. Do you remember her?
Dr. Leeds: I had received an e-mail from her husband, saying that she had undergone surgery in Mexico, had a complication and was looking for help. I told my office to request her records and received them three or four months later. I spent probably three or four hours reading every write, it was a large chart. And clearly I could tell she was institutionalized for a long time and had undergone several procedures and surgeries. I started to document every significant event that had been done which is what I normally do for every patient. I finally spoke to her husband directly. I had already known the name of the surgeon that was currently managing her, so I reached out to him and told him I would like to take her in transfer.
There’s a lot of issues involved in this story but let’s talk about what you did for her first. I guess she came to Dallas.
Dr. Leeds: Yes sir.
And then you examined her and within just a couple of days you had her scheduled for surgery.
Dr. Leeds: There were not many options left. Since she had been institutionalized, de-conditioned, the idea was to get her back to her family, get her back to a lifestyle. Reading the chart I knew we only had one option left. We had to go to surgery and this stomach needed to come out. And that was really the only option. It was a salvage procedure at that point.
It sounds awfully dramatic, had you ever done anything like that before?
Dr. Leeds: Fortunately here in Dallas we’re kind of a hub. This is a niche that really hadn’t been filled here in Dallas when I came here four years ago. This type of surgery I’m very comfortable with. I trained in a place where we did a lot of advanced surgery. North Texas seems to have a very high volume of bariatric surgery, and when you have a high volume you have a lot of complications. So, I started taking on these patients.
It pretty much gave you a career path?
Dr. Leeds: Definitely a niche that I wouldn’t have guessed I would be involved in.
You kind of had an idea of what was going on inside and then when you actually got in there what did you see?
Dr. Leeds: It was a lot of what I expected however, probably some of the most tenuous scar tissue I had ever seen.
It sounds like some of the things that the young surgeons learned in the military. It didn’t stop you but it got your attention.
Dr. Leeds: I knew it was going to be a difficult operation. Typically I do all this stuff minimally invasive with a camera and small instruments. But I knew this wasn’t going to be an operation for that.
So instead of using cameras and instrument you had to open her up?
Dr. Leeds: Yes
So then I’ve never really heard much about taking out the stomach and attaching the esophagus directly to the small intestine but how common is that?
Dr. Leeds: It’s not an ideal surgery. The way that we learned this surgery is dealing with cancer patients. If they have a stomach cancer the whole stomach has to go. And then you have open ends of the GI tract and you have to figure out how to reroute them. And this is probably the only way to have a patient continue to live with continuity of their GI tract after removing their stomach. In addition to the stomach removal, I also manage esophageal cancer patients where we remove the esophagus This was not foreign to me.
So what you do with cancer patients helped you to know what to do?
Dr. Leeds: Yes.
It still sounds awfully dramatic and were you at all concerned about the outcome?
Dr. Leeds: Every time you operate on someone with scar tissue, they can’t heal as well as the first operation. In her case, we were talking about two, almost two and a half years of repetitive procedures and operations, And so we talked a lot about the options. And I explained to her that there may be a point where I have to take her esophagus and bring it out of her neck. We’d feed her through a tube and then come back and try to reconnect her. That’s fancy surgery that we want to avoid but that was the other end of the spectrum. When I went to surgery I told her what I planned to do, and fortunately we were able to do exactly what I planned.
It must have felt pretty good about your plan and your ability to carry it out, correct?
Dr. Leeds: I think with all the experience I’ve had, I was pretty confident in the plan. I had the bailout plan set up too.
How did she do after that?
Dr. Leeds: It was a rocky recovery which we all expected. I told her we were going to be in the hospital for an extended period of time. I told her that she would have a feeding tube and that would be the means to temporarily feed her. The best thing about surgery when I feel like we’re doing a good job is when we’re anticipating all the possible problems. We have an answer when they come up and we’re not scrambling. With her family, myself, my team we talked it out and I told her we’re going to have some complications. I mean there was bumps in the road, but she continued to get better. There was bumps in the road that we were prepared for and we were able to navigate.
Now when you see her she has no bag, she does eat normal food, some things bother her she can’t eat as much Mexican food as she might have. But she’s able to lead a normal life now. Would you agree?
Dr. Leeds: Yes. She is living probably the most normal life she possibly can have which is very close to where she was before her operation in Mexico. She does have some limitation on quantity of food, a little bit of residual pain that will go away over time. The GI tract is an amazing thing, We got it healed and it’s all connected, everything is staying where it’s supposed to be. And she’s doing just fine.
No leaks?
Dr. Leeds: No leaks and she is exactly where I need her to be. We’re out several months now and . she’ll continue to get better. She’s now telling me that she’s going to start a workout plan. These are all things validating what we did.
When was the surgery do you remember?
Dr. Leeds: No, not off the top of my head.
Last year? So it was just in November, this is only six months later. To me I would say it’s a pretty remarkable turnaround, how would you describe it?
Dr. Leeds: Yes. Her recovery has been remarkable. It’s probably because she was a healthy woman before, she’s young. We did everything in an expeditious way and did it with as minimal problems as we could deal with. She’s exactly right where I would imagine her at six months.
Let’s talk about a couple of the issues involved here. She priced the sleeve, the gastric sleeve it was going to cost about fifteen thousand maybe a little bit more. She got basically the same thing plus the airfare down in Mexico for five thousand dollars. Do you recommend that people go to Mexico for this kind of surgery?
Dr. Leeds: I don’t recommend people travel out of this country for surgery. The reason why is bariatric surgery has a misconception. The surgery is not what helps you, entirely. People think that if I go and get the surgery that’s the silver bullet and I’m cured. That is not how bariatric surgery or weight loss surgery works. There’s a preoperative phase, medical weight loss, there’s a surgical phase and then there’s a follow up phase.
The most important thing is the follow up phase. When they go to Mexico to do the surgery, they leave without a follow plan. So patients that don’t know how to eat well before surgery, have a surgery and come back home but they still don’t know how to eat well.
The GI tract is good for two things. It breaks down food and stores it. You can operate on it all you want and it’s still going to do the same thing. If you are a functioning human being, you’re breaking down food and storing it. Recent studies show that after five years up to two thirds to three quarters of patients gain all their weight back regardless of where the patient has the surgery. And that’s because we’re not teaching them how to eat. So the postoperative phase is the most important. I don’t recommend anybody traveling abroad to get the surgery part without a plan after surgery.
My sister had it done and I think within five years she gained most of it back. She’s probably typical right?
Dr. Leeds: Yes, I mean it’s up there, it keeps rising.
So that’s an issue too even in this country. Sometimes people go to other countries and they have good outcomes. So it sounds like there’s a point to be made about the bariatric surgery. Would you address that, it’s not a quick fix.
Dr. Leeds: Yeah, bariatric surgery or weight loss surgery is not the silver bullet. It’s learning how to eat. The surgery helps you get on the road to weight loss and then maintaining it over time. That’s a failure in our system where we just operate and let people go, despite trying to coach them. I know that there is facilities and clinics that try to coach patients, but remember it is a patient population wher they have to want to help themselves too. They have to adhere to diet protocol, they have to manage their calories. There is an interactive part. I think we mislead patients thinking that they just have a surgery and they’re cured. And that couldn’t be further from the truth.
So it’s not necessarily that they’re doing a bad job in Mexico is it, or is it?
Dr. Leeds: The Mexico plan for weight loss surgery is a system that’s not going to work. It’s doomed for failure. So I can’t really vouch for the surgeons there because I know some of them have had really good training. And probably do a good operation. You can have leaks and complications in the United States too. The problem with Mexico surgery is now that you go there you come back there’s no plan.
Now there is an insurance side. Most patients that end up down in Mexico don’t have bariatric or weight loss surgery privileges in their contract with their insurance. So now you have a person that wants weight loss surgery, it’s not covered by insurance, so they go to Mexico. Now if a complication happens in Mexico, they come back here and insurance may not be willing to cover any complications.
She experienced that because when she came back, of course, she had already price it out so she kind of knew the doctors and things. And when she came back and she had complications she wanted to go back to those people and they pretty much didn’t want to deal with it.
Dr. Leeds: Sure.
What does that tell us about what the system?
Dr. Leeds: It really plays into what I’m talking about. When you operate on a patient, that patient is your responsibility. It’s difficult to find a surgeon willing to accept responsibility for another surgeon’s patient, especially when dealing with complications.
Well let me ask you the question and you can dance around it however you want. It seems to me that you know there are different qualities or abilities of surgeons too. And there are different levels of medical expertise especially in certain areas. And maybe without trashing or criticizing any of her previous doctors they may not have had the ability.
Dr. Leeds: Sure.
And they might have been trying with what they knew, but maybe they just were not at the same level of training and expertise maybe you are. Is that fair to say?
Dr. Leeds: I would say that in the United States we have set up centers of excellence. In order to do certain operations, you have to do them in centers of excellence. And that usually means the ancillary service understands the procedure and the surgeon has or surgeons have vast experience. The outcomes seem to be better in those regionalized or centralized centers of excellence. And that’s been proven with data to support that for cancer operations and for bariatric surgery. And so here in the United States patients go to centers of excellence to have their operations done.
Now recently that has deviated slightly where you don’t have to be in a center of excellence to get weight loss surgery. I would compare this to a trauma center. You don’t just take somebody with a devastating gunshot wound to the local ER, you take him to a major trauma center. Same thing is true in bariatric surgery. A bariatric surgery center of excellence can deal with complications if they happen.
It just kind of makes sense, not everything is equal. It doesn’t mean they are bad or anything else. But it does seem maybe the popularity of the surgery and the desire you know the public want it quick, fast, local and there’s money to be made and surgery to be done. But maybe that doesn’t always create the best outcome.
Dr. Leeds: I’ll emphasize it again. There’s a misconception, or I think the public is misled, that the surgery is the fix. So patients seek out the surgery, maybe not necessarily a surgeon that has the ability, but they seek out the surgery instead of the entire encompassing weight loss process. That’s where the fault is.
Yeah, and you see this in all kinds of different things like how many doctors who are doing one thing who are now into hormone therapy.
Dr. Leeds: Sure.
Okay, so what else would be good to know here? It’s like you don’t recommend going out of country or going to Mexico for most surgery. Some hospitals are better than others in the sense some doctors are better than others just like anything. And yet it somehow it all seems to be working out for her now doesn’t it?
Dr. Leeds: Yeah. We need to emphasize that if you’re in search of weight loss surgery, look for a hospital that has the process, not just the surgery. Now if a complication occurs in your care, surgeons do have a little bit of an ego and want to keep their patients, But, if things aren’t going well, transferring to a higher level of care is really what we need to emphasize.
To what degree does insurance play in to all that?
Dr. Leeds: Good question. I would tell you that insurance companies never complain about transferring to a higher level of care. If a surgeon is asking for that, insurance companies support that. From that standpoint, a higher level of care should always strive to get patients better, and insurance has never been a problem with that.
That’s interesting I thought that it might be in certain situations.
Dr. Leeds: If you can define that it’s a higher level of care then that shouldn’t be a problem.
One of the things about the insurance company I suppose the bottom line for them is cost and care. But actually by transferring somebody in to a higher level of care you may actually be saving money.
Dr. Leeds: Transferring patients to higher level of care will always save the institution money. The reimbursement is hard to define but numerous studies have looked at this. High volume centers have lower complication rates which saves money. That’s across the board, any operation out there that has been looked at closely. Especially in cancer operations, bariatric surgery, and complications rates for esophageal disease go down, cost goes down, and patients are out of the hospital faster.
The big factor for her was the cost going in to this so would you say if somebody is just dying to have the surgery they see a difference of price tag of like five thousand in Mexico, whatever it is should they save their money and wait for the better one?
Dr. Leeds: Patients have waited it out, I have advised patients to wait it out and get a new provider, or change their plan. Now bariatric surgery is a little tricky because some plans don’t always have built in to them bariatric privileges. You have to be in a provider that offers that.
Anything else about this either her story or the issues associated with bariatric surgery and the complications that can happen that we haven’t really talked about?
Dr. Leeds: No. Well, I’ll talk about my research.
Please do.
Dr. Leeds: I’ll talk about my research with regards to complications from bariatric surgery. This facility and my clinic, we’re the Center for Advanced Surgery. We probably handle more bariatric complications than ninety nine point nine percent of the facilities in the world. So we see a lot of complications. We know how to deal with them. In fact we’ve premiered procedures that have never been done just to handle these kind of complications. There’s more experience in this facility dealing with complications than anywhere else. We have written about it, we’ve published on it and we often times accept patients that are coming in for these complications.
Every surgery has the possibility of a complication. You look across the board right no, and sleeve gastrectomy, which is the procedure she had, has a complication rate somewhere between 1 and 2 % nationwide. If you look at how many are done, and we’re talking thousands, one to two percent all of a sudden is a very significant number. You look in the state of Texas and all the bariatric surgery that’s being done, we’re seeing a lot of complications. So I urge patients to do their homework on where they choose to have surgery.
END OF INTERVIEW
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