Good evening, everyone. Welcome to the Oxford FBMRS webinar series. I'm Dr. Kimmy Minhajji, moderator for today's webinar. Today's webinar is Health Services Research in FBMRS presented by Dr. Roy Patel. Dr. Patel will present for 45 minutes. The last 15 minutes of the webinar will be dedicated to Q&A. Dr. Roy Patel is a director of Cooper Center for Metabolic and Bariatric Surgery at Cooper University Healthcare. He has served in this capacity since 2011. His area of expertise include general and minimally invasive surgery with a primary interest in all aspects of bariatric surgery. Dr. Patel is passionate about obesity care and population health. Cooper's program is multidisciplinary and offers lifelong care for this complex disease. Dr. Patel is Associate Program Director for Cooper's General Surgery Residency and the Director of Surgical Stimulation. Before we begin, I'd like to review some housekeeping items. This webinar is being recorded and live streamed. Please use the Q&A feature of the Zoom webinar to ask any of the speakers questions. Use the chat feature if you have any tech issues. Our staff will be monitoring the chat and can assist. Welcome, Dr. Patel. Thank you so much, Dr. Menhaji. I appreciate the opportunity to speak and the invitation. Very kind of you and Melissa for organizing this. Um, let's see. As far as disclosures, I have no relevant commercial relationships, no commercial support. My only disclosure is that I operate in the polar opposite of the abdomen. So my perspective might be a little bit different, but I hope to share with you some of what I've learned and what I care about passionately about care of our patients. So today I'll talk to you about obesity, the epidemic that we're facing, whether it's a chronic disease or a new one, and bariatric surgery. We'll certainly talk about that in the pelvic floor and its relationships. Some surgical options, strategies, and patient selection. Obesity and risk assessment. I hope to talk about that as well, and maybe some lessons that I've learned and what we've learned from bariatric experience too. Perioperative considerations for patients who have had bariatric surgery as well. So is obesity a new disease? Not really, it's been around for quite some time. There's been figurines that we've come across over time dating back to as far back as 35,000 years. And these figurines tend to depict obesity in relation to fertility. Some have linked obesity to wealth and also an elite class. So obesity has been looked at in different ways during our time. Really, even back then Hippocrates wrote that corpulence is not only a disease itself, but the harbinger of others. So we've seen this relationship between disease and obesity as well. The Indian surgeon Shashuta in the sixth century related obesity to diabetes and heart disorders as well. So those links were seen very early on. We've had many studies supporting this, and now we need to figure out how to treat and manage these links as well. So when we talk about definitions of obesity, the WHO identified obesity as a condition of excessive fat accumulation in the body to the extent that wellbeing are adversely affected. And there's certainly limitations when we figure out what normal is. And some of these could be age, gender, a high variability among individuals as well. For example, newborns have about 10 to 15% of their body fat composition. This will be increased to about 25% in the first year. And this decreases slowly to about 15% at age 10. And that can be a variability between males, females, different ethnicities. So when we're talking about what is excessive and what causes comorbid conditions in people or adversity, these become really tricky when we're talking about norms. So rather than using tables all the time, we've moved towards using calculations. And one of the more common calculations that we use is called BMI or body mass index. And that's a calculation of weight in kilograms over height in meters squared. But BMI is really an estimate of risk. It's not really a true measurement. So it fails to account for fitness and distribution of weight as well. So some have used things like waist to hip ratio to identify central obesity versus peripheral obesity and its relationship to risk as well. And it fails to consider risk of disease in certain ethnic groups as well. For example, Asians and African-Americans may have a higher risk of developing diabetes or high blood pressure at BMIs of other ethnicities in the same range. So if we use only BMI to calculate or offer surgery or interventions, we may miss out often in certain populations. So what is normal? I try and tell students not to base everything on economics and finance, but this was interesting. In 1943, the Metropolitan Life Insurance Company really started to look at their patient population and they broke it down into their men and women clientele and of their weight and body frames too. So they came up with healthy life tables and they tried to look at how long people lived, how many medical problems they would develop and who could they insure and for what rate. So we really started to organize some of that data even in the 1940s. And 1960s, the National Health and Nutrition Examination Surveys were conducted and these were cross-sectional data looking across our country. And these are some of the data that we use today to look at longitudinal outcomes and future statistics. So when we talk about assessing risk, normal weight really is a BMI of 18 to just under 25. Overweight begins at a BMI of 25 to under 30. Obesity begins at a BMI of 30. And we use terms like severe obesity and morbid obesity. And really when we use those terms like morbid obesity it's to talk about a reduction in our life expectancy and also correlated diseases like diabetes and high blood pressure. When did obesity become a disease? Well, in the 1940s, the WHO really started to recognize globally that this was becoming a problem. So it was brought up in a few of their meetings but it was looked at as a disorder. And in 1948, they really started to become concerned. In the 1990s, I think the WHO came together and they really recognized the health related problems were becoming worse in overweight countries compared to countries that had problems with underweight. So this really was becoming more of a global concern as well. The American Medical Association really only defined obesity as a disease in 2013. It had been identified as a disease and disorder but they felt the need to readdress this. And that was done in 2014. And really didn't have ICD coding until 1975 when obesity and other hyperalimentation was offered as an ICD code, as well as in 1995 when we started to use classifications of obesity. So ICD codes and coding were really helpful for reimbursement, but they're also helpful for identifying risk and accruing data as well. This is data obtained from the CDC and you can see how obesity affects our country overall. And there are no states with an obesity rate less than 20%. Colorado really is in the 20 to 25%. One of the heaviest states is West Virginia. And if you add overweight plus obesity, we're talking about over 70% of the adult population. And the kind of most disturbing thing about this survey was that it was self-reported. So certainly nobody overestimates our height or underestimates our weight over a telephone survey. So these statistics have been changing unfortunately in a more concerning direction. More than one third of US adults now are obese. No state has made the Nation's Healthy People 2010 goal to lower obesity prevalence to 15%. 2000, no state had an obesity prevalence of 30% or more. 2009, we're looking at nine states. And in 2020, we had a prevalence of over 35 states that had an obesity rate of 30% or more. And when we talk about obesity, 25% or more, we're talking about 48 states. So most of our country now is affected by this disease. Looking at these trends, where have we seen most of this growth and change? Unfortunately, overweight has been stable, but really we've seen it in obesity and the classifications of severe obesity too, where men and women both have seen an increase, but women have shared this burden more than men. And when we look at the actual statistics from the NHANES, we see the overall prevalence of obesity is about 37.7%, women about 40.4%. And for class three or severe obesity or morbid obesity, about 9.9% as well. How does it affect ethnicity and race? So if we look at some of the data also affecting women, we see a statistically significant increase in non-Hispanic black, as well as Mexican-American women, as well compared to really no change in overall women. We talk about ethnicity. And some of the other disparities that women face when we talk about obesity is in income. So obesity prevalence will be increased as income decreases. With higher income, women less likely to be obese compared to lower income women. And what we found is that men, the prevalence is similar to all incomes. Also, it can be linked to education or level of education. So obesity prevalence increases as education decreases. And women with college degrees tend to be less obese than lesser educated women as well. So there can be also disparities seen within our society. The health care expenses, the total health care expenses are 31% higher in women than in men. Inpatient care and prescription drugs make up a high percentage of this. And when we look at the average inflation adjusted annual medical care costs of adult obesity overall, this rose from 3,070 in 2005 to about 3,500 in 2010, an increase of about 14%. We spend over $300 billion in cost with healthcare related to obesity. And another way to look at it is that with each one point increase in BMI, this leads to a 4% increase in medical costs and 7% increase in pharmaceutical costs. So it's important to treat BMI no matter what we're trying to achieve here. And when we look at life expectancy and how obesity affects life expectancy too, good meta-analyses that were performed looked at BMI and patients with a BMI of 30 to 35 saw reduction in years of their life to about two to four years. When our weight starts to increase and BMI gets above 40, we see a reduction in overall years of eight to 10 years. And with childhood obesity rates now in the 17 to 20% and affecting younger and younger ages, I think this is gonna be more significant in the years to come. Well, how does obesity impact our patients? Well, socially, still an acceptable form of discrimination. I don't believe so, but we see it as early as in the playgrounds, on TV. People poke fun at obesity and it really shouldn't be allowed. Job discrimination, premature judgments on character. If somebody was obese, then they must be lazy, not make good decisions, and we know that that's not true. Financially, patients can spend over $18,000 per year on diets, foods, and prescriptions. Nationally, again, we talked about over 300 billion on medical bills and weight loss products and services. Probably the most important way it affects our patients is on their health. And so we see these changes, even with the BMI of over 30, 70% increase in coronary artery disease, stroke, diabetes, and mortality as well. And as far as discrimination goes, we see that in the employment setting, there is an increased cost to employers. If an employer wants to make changes to their facilities, that's an increased cost. For example, bariatric chairs or toilets, we certainly went through those changes in the facilities where we've created programs that are accommodating to our patients with weight. And creation of wellness programs, patients may feel targeted or compelled to join these programs. Healthcare, patients have also recognized, and there's data talking about providers spending less time and less health education because the topic is a difficult one to talk about. Patients report feeling disrespected and report weight as a blame for all the medical problems as opposed to addressing the problem and identifying the disease itself. And they're less likely to undergo preventative cancer screening, which is really tough because obesity is a increased risk factor for formation of many cancers. Public health changes as well. Current approach is focused really on education rather than focusing on a more comprehensive approach where we need to go next. And how does weight loss just in general affect comorbidities? Well, you can see there's very good data to support that weight loss has an association with many diseases, including diabetes, sleep apnea, cancer, osteoarthritis. Many studies showing those links as well. So going back and kind of confirming what Hippocrates and Shushruta found a long time ago. And this is why we treat weight no matter what the BMI is because it can affect so many different organ systems. Centrally, idiopathic intracranial hypertension, stroke, and cataracts. Probably the more talked about diseases like diabetes, high cholesterol, hyperlipidemia, hypertension, pancreatitis. Obesity now has superseded smoking as a modifiable behavioral risk factor for the formation of many cancers, hormonally driven ones as well. Colbitis and venous stasis, gout, skin changes, osteoarthritis on the joints that bear weight. And certainly gynecologic abnormalities, including abnormalities in menstrual cycles and fertility and polycystic ovarian syndrome have links to obesity as well. Gallbladder disease, certainly different grades of liver injury. We see it in steatosis, which is body changes of the liver when the cells are injured and becomes hepatitis and can lead to cirrhosis and a need for transplant as well. About 77% of our patient population may have underlying sleep apnea, which can be really important, especially when managing critical patients in the house and sedation as well. We talk about causes. I just wanted to put a shout out to Adele Davis. She was in the mid 20th century, considered one of the most famous nutrition experts and really one of the first early textbooks on nutrition. And she recognized and had a quote, to say obesity is caused by merely consuming too many calories is like saying the only cause for the American revolution was the Boston Tea Party. So essentially very complex disease and she recognized it at that time. I think there's certainly a component of genetics, behavior, environment. I wish it was this simple. We had three nice little circles and right in the middle, that was the treatment option. But within each of these categories, we're learning more and more every day. So certainly a complex disease, but the one that has components of one or all of these and may shift at different phases of somebody's life. So important to understand how that could play an impact. As far as genetics goes, there's been multiple twin studies, adoption studies and obesity genes that have been coined and identified. There have been leptin and ghrelins, basically adipokines. And we'll talk about that a little bit more. Decrease in stretch receptors in different parts of our intestine. And the central effects of obesity and satiety and the hypothalamus. We'll talk about that as well as evolution. Behavioral changes, certainly family tradition, food to comfort children and addiction. We see gender changes and causes in obesity. It's higher in females, socioeconomic, whether it's high or low income classes and cultural views. Psychosocial, certainly coping mechanisms, behavioral health, how we manage stress. We don't have a lot of that teaching early on and food and the things around us are what we turn to. Societal technology has decreased the energy expenditure. Certainly it's made it easier. And elevators, power windows are examples of these. Healthcare infrastructure and public policy. Again, around sometimes end stage disease and not so much around preventative care as well. So certainly we can pay more attention to that. We see the effects of obesity, even in the perinatal timeframe. So obesity and pregnancy can affect and be associated with a higher insulin resistance and inflammation that causes increased adipose tissue lipolysis. This results in increased maternal circulation of lipids, which cross the placenta, and that can lead to an increase in metabolic disease in childhood. So certainly an interesting theory about how that can affect us during pregnancy development and even in early childhood. Individuals have looked at breastfeeding and is that protective or not? And certainly we've seen links to say serum levels of ghrelin, leptin, and insulin have been shown to be lower in breastfed infants at one, three, and six months. So a protective effect of breastfeeding as well. There've been studies like adoption studies, and this was one looking at 540 adult Danish adoptees divided into four weight classes. And what they found was a strong relationship between adoptees and the BMI of biologic parents when they compared it to adoptive parents. So no relationship with the adoptive parents. So it raises that question of nature versus nurture. And twin studies, there have been also twin studies, and I cited one here, looking at monozygotic versus dizygotic twins. So individuals have tried to look at the differences there and they found a concordance rate for excess weight was twice as high in the monozygotic twins and the dizygotic twins. There've been over 40 genes that have been identified for obesity, but they're usually linked to a very small subset of population and not everybody. And there have been the thrifty gene hypothesis as well, which we'll talk about. So why did evolution select for such behavior if it's detrimental to our health? And I think when individuals really think about it and talk about it, it does come up. One of the theories has been reproductive fitness and that trade-off for long-term health. And certainly in times of famine, in times where individuals just had to move long distance or migrate, this was the focus and allowed for improved survival. So why do we choose adipose tissue? Certain other species are lean and do quite a bit of work, but in humans, we need calories, not just around early development, but we need that throughout our life for brain development, skeletal development for a longer period of time. So human body sort of when we look at fat versus other tissues, I found this to be interesting as well, that less than one day worth of calories is found in skeletal muscle in the form of glycogen. So we would burn that up very quickly. Whereas we have over two months worth of calories and fat. So that becomes important when, again, dealing with famine and drought. Why did metabolic diversity evolve in humans? Well, we inhabit virtually every environment on the globe. So over generations living in certain environments, island and a mountain, certainly there's going to select out certain phenotypes as well. The idea of metabolic thrift was developed by James Neal at the University of Michigan in 1962. He theorized that the constant pressure of famine led to selection of genes that regulated metabolism in a highly thrifty manner. This provides a reproductive advantage. So again, going back to reproduction in food sparse areas, but leads to obesity in environments where food is plentiful. So again, very good observations and theories for where we are today. And now we're looking at the pathways, but even in my lifetime, it doesn't take a lot to look around you as far as environment goes and see even our portion sizes have changed. There are marketing influences that happen on food products that we're around. So these are the other things that are around our current environment that play a role. You see reduced frequency of family meals, increased consumption of fast foods. There are over 30,000 products in supermarkets each year, about 12,000 new food products per year. I was just talking to my dietician the other day. We were just talking about different types of Greek yogurt. Now there's a whole aisle for just Greek yogurt. So before it was tough to even find that to begin with. What causes obesity? There are some other causes as well. Sleep health certainly has been linked to obesity and metabolism. Behavioral health can be bidirectional. Certain medicines may increase our hunger or appetite as well as our mood and behavior overall. It may affect the way that we approach food. So circadian rhythm. Our work hours, if we work nights, using screens affecting melatonin in our brain centrally, that certainly can affect obesity and our metabolism. And other comorbid conditions, hypertension, diabetes, the medicines that we use to treat them and how they influence our ability to eat and exercise. Another interesting theory regarding the causes of obesity revolves around our gut microbiome. So there's been a lot of good research and Collado and colleagues looked at the effects of the mother's weight on infants microbiota. So they followed pregnant and non-pregnant, I'm sorry, overweight and non-overweight pregnant women and their infants. And what they saw was an increase in certain organisms that are associated with obese populations and a decrease in others. And this same pattern was passed on to offspring. So certainly could the gut microbiota play a role in obesity? And even at our institution, we're looking at the gut microbiome and how that affects weight loss in post-bariatric patients as well. So a lot of neat research that's going on with gut microbiota and theories as well. Adipokines, and what an adipokine is, is essentially a hormone or a cytokine that's released from the adipose tissue. And it can either work locally or centrally. Two of the more popular adipokines that have been identified have been leptin and ghrelin. So leptin is released in the peripheral fat and it works centrally in the arcuate nucleus of our brain. And what it does is it binds to receptors and decreases the appetite overall, helping us to control our weight. When there's dysfunction in the receptor, this can lead to an unregulated amount of leptin secretion and also obesity or hyperphagia. It's a pro-inflammatory. It does activate NADPH oxidases which release hydrogen peroxide, which can then cause oxidative stress. So another cause for local pelvic floor dysfunction and other dysfunction in parts of our body. Ghrelin is considered orexogenic and that's secreted from the stretch receptors of the stomach and what happens with ghrelin is it's released. Another theory behind why which bariatric surgery works so well by either removing these stretch receptors or decreasing the amount of stretch that happens in those parts of our stomach, we help with satiety and to control appetite as well. And other theories that have helped to support this are studies. In the 1940s, hypothalamic ablation in rats was found to induce hyperphagia as well. So all neat theories that have, or studies that have helped to support this pathway for obesity as well. Other adipokines like adiponectin is an anti-inflammatory. This is found to be reduced in function in obese individuals. Free fatty acids are increased, impaired insulin sensitivity, and this can affect the regenerative function of the blood vessels. So all theories behind how they affect things like muscle and our pelvic floor, other organs in our body as well. And how important is the distribution of our fat? Well, certainly if it's central versus peripheral, this may have other impacts on disease processes. So I see it when I'm operating in the diaphragmatic hiatus, where we see idle hernias or umbilical hernias in obese population who have more central weight. And I think that's certainly an accepted theory behind why pelvic floor disorders happen as well. So we currently use BMI to identify risk, but should we be really looking more at the distribution of fat? And how do we identify that to help us guide our interventions with patients as well? The mechanisms of injuries to the pelvic floor, well, chronic increase in intra-abdominal pressure, change in pelvic musculature, nerve damage, and obesity related to comorbidities like diabetes, diabetic neuropathy, and inflammation as well, as well as oxidative stress created by things like leptin and cytokines released from the adipose cells in the muscle and in the pelvic floor. When we look at prevalence overall, pelvic floor dysfunction, when you look at non-pregnant women, greater than the age of 20, at least one pelvic floor disorder will be seen in about 23% of patients. And urinary incontinence will be the most frequent. When we talk about the obese population, this really does increase quite a bit. So morbid obesity, about a 57% increase in the prevalence of your obesity as well as obesity. Obesity carries a fourfold increase in the risk of urinary incontinence and twofold increased risk in the risk of fecal incontinence as well. Is bariatric surgery beneficial in treating pelvic floor dysfunction? So I came across two very good meta-analyses, and this included over 28 studies, and it helped to form that direction and answer the question, is obesity a modifiable risk factor for urinary incontinence? And they did find that. Patients undergoing bariatric surgery did benefit from a greater than 60% reduction in urinary incontinence risk. But the data behind fecal incontinence and pelvic floor dysfunction also was mixed. So in bariatric surgery, I think another meta-analysis was found, and this looked at 11 cohort studies. So bariatric surgery was associated with a significant improvement in pelvic floor dysfunction as a whole here and significant improvement in urinary incontinence as well as pelvic organ prolapse with similar findings with mixed results as well as fecal incontinence too. So some of the discrepancies when we look at these meta-analyses are that the reporting was definitely heterogeneous where outcomes and duration were reported differently as well as the quality of the data, the differences in surgical technique, follow-up and outcome. So certainly we need more randomized prospective studies. This was also an interesting study by Plameen who looked at surgery and asked the question, could it be prophylaxis for the pelvic floor? And has anybody really looked at the anatomic changes and functional changes? Most of the studies that we do when we look at obesity and pelvic floor are surveys and questionnaires. So what the individuals did in this case was do pelvic ultrasound both before and after bariatric surgery, looking at that data 12 and 18 months post-op. And it was prospective non-randomized and it looked at overall 59 patients. So we found a higher position of the bladder neck at rest during tension and at Valsalva, which may help to explain some of the improvements around urinary incontinence. No difference in bladder neck mobility and bladder neck elevation after weight loss. So also helps to explain why maybe we don't see improvement on patients that have had pelvic organ prolapse or injury already to the pelvic floor. When we talk about fecal incontinence, this was one interesting study looking at 101 women were prospectively followed before and after laparoscopic urinary gastric bypass. And it showed actually improvement in incontinence of solid and liquid stool, but worsening when we talked about flatus as well. And just one interesting point about bariatric surgery is that there's definitely changes to the GI tract that can be affected by the type of diet. So that was one of the thoughts behind this. And most of the meta-analyses really were difficult in finding good power to support whether fecal incontinence is improved with bariatric surgery or not change at all. So a couple of variables that can affect fecal incontinence data. So pelvic organ prolapse, noted this, the WHI hormone therapy clinical trial was a cross-sectional study. And what they showed was an increased risk for prolapse in women with a BMI of 25 or higher. The longitudinal effects of obesity on prolapse and post-menopausal women during five-year period followed as well. And the findings were interesting in that obesity was associated with progression of prolapse, but with weight loss, there was no real improvement with prolapse regression. So once the damage is done, it's very difficult to change that, but certainly can reduce the progression. And there's not a great deal of literature out there. I found at least to support whether weight loss surgery will affect outcomes of pelvic floor surgery and interventions as well. So another area of further research. So should all patients have bariatric surgery? Well, if you ask a bariatric surgeon, just kidding, you probably would get mixed responses to that. But when we look at the general health perspectives, these are going to be improved. So if a patient meets criteria, that's certainly going to help them from an overall standpoint. And it may actually help to prevent further pelvic floor disorders. So talking about options and weight with patients is really an important thing to do. Access to care. Not everybody has insurance that covers bariatric surgery. Believe it or not, there are some insurance companies that look at this as cosmetic, and they may also require medical necessity and can exclude it from different insurance policies. So it's important for patients to understand their insurance benefits and what those requirements might be. Patients would certainly be ready for this kind of a commitment. It does have some inherent risk and it does take some long-term commitment, but where patients are willing to make that and have been doing that, surgery has a really good option for patients as well. And it does have a mortality risk, although low, it is present. 2.13%, and an overall risk of major complications of about 4%. So we need to employ a comprehensive approach and not jump right to, I think, weight loss surgery, even though the data would suggest that it's a very good option for patients. I think it's definitely the most. So goal setting is an important part of our comprehensive approach. But lifestyle change with a target of about 5% to 10% baseline weight loss within six months, we can achieve that great, we keep moving. A total dietary intake of about 1,200 to 1,500 kilocalories per day. And that's easier said than done. So certainly working with an expert, like a dietician or somebody with expertise in helping counsel patients on how to shop, cook, and identify foods that are healthy to meet these targets is important. Physical activity, recommendations from the Health and Human Services Division recommended about 60 to 90 minutes of moderate to vigorous activity. But I really try and focus on consistency. Consistency is important to raise basal metabolic rate for patients. And certainly pharmacotherapy can be added as an adjunct. Even in the best medically supervised diets and weight loss programs, about 95% of patients will regain weight when we talk about long-term statistics. That's really difficult. So we need definitely more interventions, but more focused approach to weight loss, both from a surgery and non-surgical aspect. So Sue Beck and colleagues also reported a 50% reduction in urinary incontinence frequency with only 5% decrease in weight. So it's really important to treat weight no matter what the VMI. And this can be achieved with modest gains as well. When we talk about bariatric surgery, there are roughly a little over 200,000 operations performed in the United States annually. This number has been fairly consistent. And interestingly, that accounts for 1% of the clinically eligible patients in our country that may need bariatric surgery. So there are plenty of patients out there that would benefit or meet this criteria, whether they have access from an insurance standpoint or being counseled or educated about it. I think that's where the gap or divide might be. When we look at the incidence of bariatric surgery among women, we've seen the incidence increase 800% between 1998 and 2005. So many of our patients that you are taking care of either have had surgery or may be good candidates for it. Women of reproductive age, we looked at that patient population and that accounted for 84% of the bariatric surgery patient population as well. Again, when we talk about who qualifies for bariatric surgery, at what risk, we're using BMI to associate risk. In 1991, the National Institutes of Health came together and they identified a BMI of 35 with a related disease like diabetes, high blood pressure, or a BMI of 40 alone. Now that was in 1991. That was before we did things laparoscopically, before people like me did fellowships. There's been a good amount of data to suggest this could be offered to patients, certainly with disease processes that happened before that BMI, but these are the current standards and these are the ones that we do offer to patients and would be considered standard care. Some of the data, I just wanted to touch upon some of the foundation data that allowed us to be able to offer bariatric surgery, not as just cosmetic, but show good long-term results came from Dr. Buchwald. He looked at also good meta-analyses over 22,000 patients and found an excess body weight loss of 61%. Very good results. Most of us need to lose about 20% of our excess body weight before we start to see effects on diabetes and high blood pressure. Very good outcomes. This was a Swedish obesity study, just controlling over surgery to a control group undergoing best medical, medically stabilized weight loss. We looked at over 4,000 patients. Very good follow-up, 10-year follow-up. It showed a reduction in overall mentality by about 24%. Reduction in cancer deaths, reduction in MI, stroke, heart disease. Again, some very good foundational papers coming out of Sweden, where they have a government-run health system and can follow patients in a randomized way. And when we look at weight and patients ask me about which one's going to lose more, I try and counsel them different ways. And we're just looking at these three types of operations. And most of the patients are going to lose about 55% to 65% of their excess body weight in about 18 months to two years. So it's not like they're waiting a decade for these results. They're happening fairly quickly. So even timing around other interventions like knee surgery or pelvic surgery, I think can be accomplished in a fairly reasonable timeframe, so long as they have the time to move forward with surgery as well. When we extrapolate this scale out to years, five years and seven years, these graphs then start to become a little bit closer together. And this was Dr. Whitgrove and Clark, two surgeons in California who identified their outcomes in 2000. And this is really what got me interested in bariatric surgery is that there are very few surgeries that can affect so many chronic conditions at once. And it was neat to watch patients come off of the diabetes medicines or high blood pressure medicines and know that you were improving their quality of life as well, allowing that to happen as well. So that's what got me interested in surgery. And I thought I'd just mention this kind of intervention or paper as well. So this was supported by multiple other papers looking at obstructive sleep apnea, high blood pressure was improved in the majority of patients, type two diabetes. And I think with other diseases, we have looked at that data in a similar way and certainly look forward to looking at more data from a pelvic floor disorder aspect as well. And these were some papers that were recognized by the New England Journal of Medicine, really now focusing on diabetes and how it can affect diabetes, which has a tremendous burden on society as well. So there's been support from the American Diabetes Association, American Heart Association, the International Diabetes Federation, and the American Association of Clinical Ophthalmologists. Well, how safe is bariatric surgery? Well, in 1954, I would probably say not very, but these were some of the pioneers. These were surgeons who were struggling with patients. This fellow, Edward E. Mason, lived in Iowa. He just passed away this last year or two and was a surgeon, general surgeon, and struggling with obese patients who had recurrent ventral hernias. And so he saw some of the positive outcomes that were happening with surgery that he was doing for cancer and for ulcerative disease, and he applied that to patients who had recurrent ventral hernias and invented the gastric bypass. So I always look back and think this is not really a long timeframe and kind of like the Wild West to get to where we are, but we've learned a lot from that. Some of the foundations and theories of what we do today came from these types of interventions, and really laparoscopy happened in 1994. So we've taken an operation that has high morbidity like hernia recurrence and blood loss and deep incisions in morbidly obese patients and turned that into an operation that we can do for usually five millimeter trocar incisions. And what has made it even safer was the need to organize. So these are some of the associations and evolution right now. We have the MBS QIP, which is a combination of the American College of Surgeons and the ASMBS. So that looks at ways to improve quality and safety for patients and standardize the processes and outcomes, but it makes it safer and gathers data and it helps us to form our direction. So there's over 800 centers in the United States and there's centers across the globe as well. And again, it sets standards. We have a data registry, which is supported by each program and institution as well. So it helps with quality and safety for our patients. This has allowed us to really reduce the morbidity and improve the safety overall for our patients as well. So when you talk about how safe is bariatric surgery, well, lap coli, hip replacement, and CAB certainly carry a higher mortality than bariatric surgery. And our patients are usually very well screened and informed before going to surgery. We do preoperative testing and screening and each program may differ a little bit, but in general, at least in my practice, we look at the heart because weight can affect cardiovascular system, the pulmonary system as well. So we work with our colleagues, the cardiology team and pulmonary team to screen for disease. We have a nutrition evaluation and psychology evaluation. We may use gastroenterology or work with our GYN colleagues developing strategies around heavy menstrual cycles, fibroid, uterus, other diseases as well, and some screening tests to help identify related diseases as well as treat them for surgery. So we do a nutritional assessment and we educate our patients as well. And when we talk about surgery, we're really going to classify them into three broad categories, restrictive, malabsorptive, and a combination of both. And, you know, if you take 10 surgeons, you'd probably come up with 10 different techniques to do very similar operations. So there can be variability with the surgical technique, but these are essentially the different techniques that have been performed in the last 10 to 20 years. And I'll tell you about the three most common, actually four most common, and those being the gastric bypass, sleeve gastrectomy, band, and biliopancreatic demotion. So with an adjustable gastric band, this is a surgery that's an example of a device that's used. Silicone is buckled around the upper stomach. It connects by tubing to a port system, and that port sits underneath our skin and above the muscle layer. And physicians and surgeons and nurses can access this port in the office with a needle, a Huber needle, and they inject fluid into the band and they cause the interval to be tight. The primary mechanism is restriction. It has very low complication rates and morbidity. It is adjustable. It was approved through the FDA in 2001. It has short operative times and short stay. Maybe you have some of the advantages, but I think the disadvantages have been found in that there's really a lot of follow-up that happens with the band. You need to come every one to three months for band adjustments, and that's really difficult for people to take time off of work to get that done. And there are possibilities of long-term complications like slippage, which can result in dysphagia and difficulty over time. So because of these and with better interventions, I think there are fewer and fewer bands that are being performed in the United States, but these are devices that you may come across in the patient population as well. The vertical sleeve has really taken the place of the lap band, I would say, in most institutions. This was approved by most insurance companies about 2007. And with this operation, we use a calibration tube called a Bougie, and we divide the stomach and we retain the stomach along the lesser curvature. That's the more muscular part of the stomach that doesn't distend, and we remove about 85% of the stomach. Now, this fundus is the one that contains most of the ghrelin secretion and the stretch receptors of the stomach as well. So we're removing that portion of the stomach completely, and now patients will feel full quicker with a smaller amount of food. It doesn't change their choice. So if they may eat small amounts of junk food and poor quality food, they can get into trouble and still gain. So this is why it's important that patients have long-term follow-up and education as well. The surgery takes about an hour, about an overnight stay in the hospital in most institutions. The weight loss that's expected is about 55 to 70% of the excess body weight, and it is effective in reducing other comorbidities as well. Again, we talked about ghrelin and the fundus of the stomach, and we see ghrelin reduction in other surgeries as well, but it's more profound in the vertical sleeve. It's one of the fundamental theories about how it works very well. When we talk about Roux-en-Y gastric bypass, this is probably the gold standard of operations, and it's been performed again since the 1960s with different variations, but the technique that most surgeons apply today involves dividing the upper stomach and creating a small pouch. It's about the size of a hard-boiled egg or about 20 to 30 cc. We make another division further downstream, about 50 to 100 centimeters, and we bring up a limb to make the connection above and a second connection below. Now when patients eat, it takes a smaller amount of food to give them that feeling of fullness. That moves and bypasses most of the stomach, the first portion of our intestine, and meets up with the gastric juices and enzymes a little further downstream. We are away from the pelvic floor, but certainly this part of the intestine can be adherent to the lower part of our abdomen, and it may be involved or encountered when we're dealing with the pelvis as well. It's important to have an idea of the anatomy, but certainly if you need help, consult your diatric surgeon. And again, probably the most experienced worldwide, the surgery takes about two hours. It's usually about an overnight stay in the hospital, and the expected weight loss is very good as well. It works primarily by restriction and malabsorption, and has some hormone changes like an increase in GLP-1, which is really why it's very, very effective in diabetics is the theory. And it's particularly effective in patients with acid reflux and, as we mentioned, diabetes. I wanted to teach you about dumping syndrome, and I'm not sure if I have it in another slide, but essentially what happens is when we eat a high calorie or a very concentrated type of liquid or sugar, for example, would move down the upper part of our intestine that we just made to the stomach. And when it does go down this portion of the intestine, two changes happen. The body sends fluid from outside to inside the intestine to offset that concentration, and that could lead to diarrhea. And about two hours later, our body may release insulin, and so because of that surge of insulin, we may see low blood sugar. So that's the second phase of dumping syndrome. Why that's important, I think, for all people to know is that when we order diets post-op and when we're talking about fecal incontinence, that's the part that can get people into trouble where they can develop diarrhea, flatulence, if they choose the wrong type of food. So fecal incontinence may also be affected by our choices in food in patients with bariatric surgery. This does require lifelong vitamin supplementation because parts of our intestine are bypassed, certain cells will no longer see certain types of food and nutrients. So we do take a multivitamin daily and check labs periodically. The biliopancreatic diversion is an example of both restriction and more malabsorption. So in this operation, we combined a sleeve gastrectomy with a bypass component of the operation. So a very long portion of our intestine is no longer going to see food and the common channel is further downstream. So it adds more malabsorption, which leads to sometimes statistically more weight loss and can be more effective in patients with diabetes. But traditionally, this was applied to patients with super, super morbid obesity and definitely has some required closer follow-up and vitamin supplementation. You can have a little bit higher complication rate, so one to be considered as well. Some of you may have read about the intragastric balloon. Is FDA approved? These are not approved through most insurance companies because it doesn't have very good long-term data yet. And what it is, is a silicone balloon that's deployed using endoscopy into the stomach. Patients usually have to have the balloons removed in six months. So the real questions are, will patients regain weight? But early data at one year, it is good for modest amount of weight loss. So it's a modest amount of weight loss. So it's identified for patients who have a small amount of weight to lose, but certainly where technology is improving in ways that we can intervene for our patients who are requiring that type of weight loss. And so what we're looking for is really sustained comorbid conditions being drawn. This is very good data, looking at 10-year data in relation to co-related diseases. And we see after renal gastric bypass, we're able to sustain reduction in these co-related diseases. Not just short-term interventions, but long-term successful interventions. Thinking about complications can occur. And I just mentioned this to show you how our anatomy, because we've made changes, can lead to things like internal hernias or twisting of the intestine. And this is a rare complication, but one that needs to be paid attention to. Vitamin deficiencies can occur in our patient population. So certainly counseling before an education, but long-term follow-up. Patients that do develop heavy cycles, other areas of blood loss in the GI tract, like hemorrhoids, certainly we have to keep an eye out for iron. But vitamin deficiencies could also be very important for wound healing or any other surgical intervention. So if patients haven't had vitamin supplementation, I would screen for that prior to intervening on a public floor. And we talked about changes that can happen in the GI tract, like diarrhea, dumping syndrome, certain sweeteners can do that too, fatty acids. So all counseling that we perform before surgery and help patients long-term after as well. Constipation can affect the pelvic floor. So just like certain foods can affect our GI tract in one direction, decrease in water intake and certain types of foods can certainly cause constipation, which can result in straining and damage to the pelvic floor as well. So important considerations for post-bariatric patients as well. So I just wanted to talk to you about optimization considerations for the obese patient. And morbid obesity or obesity, when you compound it with things like cigarette smoking, you really can get patients into trouble. So we spend some time on smoking cessation. And when you look at the data, smokers have an increase in the odds of prolonged intubation by 63%, re-intubation by 61%, sepsis shock, and overall increased length of stay. So certainly smoking cessation can be instrumental here. We advocate for at least four weeks of smoking cessation and that improves platelet aggregation and other aspects of our immunity. And a majority of patients will return to smoking within six to 10 months. So it is unfortunate, but a reality. So I think we have to ask the whys of why people smoke and make sure we're not just intervening on the time of surgery, but providing good long-term tools as well. Nicotine replacement, when researching nicotine replacement, it does improve success rates by 60%, but when we look at e-cigarettes and other alternatives, not really much support for those, and vaping could be harmful is what we're finding. So I'd be careful looking for those alternatives. And marijuana, we've seen about 10% of Americans, but we're gonna probably see more use of marijuana. Usually there's no filters when you smoke marijuana, but interestingly, about three to four cannabis cigarettes can be equal to about 20 tobacco cigarettes when we talk about marijuana irritations, something that we counsel patients on reducing as well. Preoperative glycemic control, about 20 to 40% of the obese population will have undiagnosed diabetes. So we definitely screen for diabetes. We manage that before surgery and help them to reduce that as well. When a review was done of over 55,000 patients with diabetes they found that the pre-op A1C really did not affect the post-operative infection rates, whereas the infection rates were affected by post-op peak serum glucose and mean serum glucose as well. So maybe the preoperative intervention is important, but not as important as the intraoperative as well. So checking your blood glucose before, during surgery, intervening with either an insulin drip or aggressive therapy around the time of surgery all helps to reduce surgical site infection length of stay and complications in that patient population. The nutrition assessment, I'm very good at surgery. I know where my limitations are. I like nutrition, but we have nutritionists who have an expertise in that as well. So I'm fortunate to have that. I think if that's something that's available to you I would highly suggest that, but we certainly should be taking weight histories, identify eating behaviors and patterns, our medical history to see if there's medications that could affect it like steroids, body composition and energy requirement, nutritional status. And interestingly, most bariatric surgery patients when they present to us preoperatively will have at least one micronutrient deficiency like I do, so optimizing those will help outcomes as well. So we encourage a preoperative weight loss program and we do at least two weeks of a high calorie, sorry, a low calorie, high protein diet. And what the data shows in operating on the foregut is there's a reduction of liver volume by about 15 to 30%. So that's been shown to reduce liver injury, allowed us to operate quicker, have lower operative times on the table, get patients off, less chance of rhabdomyolysis. So I don't know that there's many studies in the pelvic floor or in the pelvis in general, but certainly fat distribution in that area I would imagine would be enhanced when we decrease central obesity overall. Preoperative medical screening, looking for related diseases like dyslipidemia, about 40% of our patients will have this. Cancer screening, gout, important consideration as well. Hypothyroidism and risk assessment from a heart standpoint and a lung standpoint as well. Physical prehabilitation, there's been a lot of interest in this as well. When you look at the effects of major abdominal surgery, the estimate is about a 20 to 40% reduction in functional capacity of patients in general. And so this can increase morbidity, it can increase the length of stay and the patient's recovery overall. So we wanna emphasize exercise, even if it's small amounts of moderate exercise before surgery. So we do that in our patient population and the obese patient population as well. So we should personalize that and not tell them to go out and do things that could injure themselves. Pulmonary interventions using incentive spirometry before surgery, teaching people, really setting expectations of being out of bed quickly is gonna help to affect adalactasis and pulmonary embolus as well. Use of CPAP and identifying obstructive sleep apnea. So if our patient population has a high risk for this, we should be doing stop bang scores or a groan questionnaire and identifying them and treating them for sleep apnea, both pre and post-operative timeframe as well. And the majority of my patients and not every practice does this, we go right to BiPAP in the recovery room and I've seen a reduction in adalactasis and I have not had really any re-intubations in many, many years, which I think is a good thing to know. And operative considerations for obesity. Certainly within the OR, touching base with our colleagues and anesthesiologists are preparing for the airway. So an airway assessment before surgery, whether a patient needs fiber optics or nasotracheal intubation can be important. Use of PEEP inside the operating room, blood pressure cuff. So we may not think about that too much, but sizing the right cuff for the arm is gonna be important from monitoring blood pressure and manage that in the operating room as well as after. IV access, because the distance between the skin and the veins, occasionally this can be difficult, we can lose access. So determining who's a difficult access, should we get one or two IVs can be important in the consideration. Certainly DVT prophylaxis, mechanical and chemoprophylaxis is advocated, but in a more of a Leo based population, you may wanna consider stratifying that to different levels of obesity. The operating table should be able to accommodate an obese patient. There are tables that can accommodate over 1000 pounds and 800 pounds in different positions. I would say we used to follow CKs many years ago in our patients. And it was kind of interesting how pretty much all patients, you would see a bump in the CKs, whether that turns into rhabdo or a decubitus ulcer, I think you have to be vigilant about making sure you're efficient in the operating room, your timing is good when you're dealing with an obese patient or general anesthesia. Early CPAP, we talked about caution with use of continuous rates on PCA. Certainly CO2 can build up and the patient can have an adverse outcome from over toxification with narcotics. And early ambulation can be really important. Just the physiology of standing up takes the weight off the abdomen and allows the patient to breathe and expand those airways. So things to consider, maybe in a patient who has had bariatric surgery, again, identifying nutrition, if you're gonna operate, you definitely wanna make sure somebody has the building blocks to succeed in healing. Have they been compliant with their supplementation? And if not, do we need to administer that screen for that? B1 is the shortest half-life. So we can actually create Wernicke's if we give somebody sugar in their IV fluids, if they have a deficiency of that. Avoid NSAIDs, because non-steroidal anti-inflammatories like Gasparin, Motrin, Aleve, can lead to ulcers within the gastric pouch. So if you can minimize or reduce or eliminate that, that would be wonderful. Avoid blind placement of nasogastric tubes. So sometimes in the postoperative ileus, we may need that. And I think that's not one that you give to your intern or somebody who doesn't feel comfortable. It's really one that should be placed under guidance and carefully. Interoperative adhesions and the involvement of the anatomy can become complex, as we had talked about before. So certainly, preoperatively, if you anticipate adhesions, you can consult your bariatric surgeon. I'm sure they'd be happy to help. And when ordering a diet, how that can affect things like fecal incontinence, I think pay attention to that. If there's questions, certainly reach out to a dietitian or a bariatric program, and they can help you to avoid dumping syndrome. So, you know, I really appreciate everyone's interest in this topic, and I hope I did give you a broad overview about bariatric surgery and how it's related to pelvic floor disorders. I found this, and I thought it was interesting. This is Arthur J. Cramp, who was director of the Bureau of Investigation and Propaganda for the American Medical Association in the 1920s. And he said virtually all so-called obesity cures except those products containing dangerous drugs are simply shrewd schemes for fooling the elderly. And the purchasers of most of them are being kidded by experts. So I really do appreciate your interest in evidence-based medicine and your interest in counseling patients. I think if we just leave it up to patients to tell them to go lose weight without creating comprehensive plans and communicating options, that we are leaving our patients susceptible to this type of these products and industry, which may not be the safest for our patients as well. So to leave you on that thought, I truly appreciate your interest in this topic and obesity. So thank you. And I will take any questions. I left my email there. So if anybody has a question down the road, please feel free to reach out. I'd be happy to answer those as well. Thank you so much for that great talk, Dr. Patel. We have 15 minutes for questions. Please, you can submit your questions in the Q&A section. Let's see if we have any questions. So I'll actually ask you a question. I really appreciate that section you had towards the end about all the preoperative workup to consider. I think as our patients are becoming more obese and knowing that obesity leads to pelvic floor disorders, so we're operating more on patients that are obese just because of that itself. At what BMI do you suggest doing that extensive of preoperative-like assessment? And if so, how do you do that? And if so, how do you do that? Doing that extensive of preoperative-like assessment and workup on patients? That's a great question. I think, you know, in our patient population, using those questionnaires can help. So things like a stop-bang questionnaire looks at the circumference of the neck, an Epworth sleepiness score. These are good directional questionnaires really that don't take much time that an MA can do that you can do to help direct you to whether weight is affecting their airway. We talked briefly about the distribution of weight. So I may have somebody who's 500 pounds that holds most of their weight in their legs and very little in their neck. So that patient may not have as much risk in their airway as well. So I think we need definitely more focused screening or tools to help answer that question at what BMI should we start screening? But I think there are a lot of good directional tools that we can use that help to identify that. And then the next question is if they test high or they have a high risk, then we would take that to the next step of consulting other physicians. So I don't think there's a hard rule of saying at this BMI, everybody should get the full Monty workup, but I think maybe incorporating some of these screening tools into your general practice, especially when dealing with obese patients is a good idea. And that's actually what we do in our practice as well. We don't like to send everybody for an invasive study if we can avoid it. Blood work, perhaps adding an A1C into an obese population because different ethnic groups, different BMIs may be affected differently. I've met patients with BMIs of 30 that have all those related diseases like high blood pressure, diabetes, sleep apnea. So I think, again, screening is probably the first place to start. I think with a BMI of 35, I'm sorry, 30, we start to see these diseases start to become more prevalent. So if you had to hold me to a number, I would say anybody with a BMI of 30, we should start that screening process. And interestingly, when I was reviewing your literature, our literature is that BMIs of 25 were associated with increase in urinary incontinence and the effects of the pelvic floor too. So again, it goes back to that question of distribution. How does it affect the pelvic floor versus globally? So good question. I hope that answered that. No, that was great. Thank you. Definitely, really appreciate that. Does that topic come up very much, Doctor, about bariatric surgery? I mean, I think definitely in the population we're seeing, we refer patients to our bariatric surgeons a lot. We have a great center here at Mount Sinai that we do that with, especially a lot of our patients who have, I think it's a great conversation to start when they come in with something that's bothering them, like urinary frequency, urgency. Any of the urinary symptoms is what's bothering them, but it's easier, I guess, sometimes to ignore the other medical issues because they're not affected by it on a daily basis as much as they think they are. So we definitely use having their pelvic floor dysfunction as a gateway to start having the more serious conversations and referring them and having them get the help they need to help them in every way. Oh, I think we have a question. Will weight loss help diabetic neuropathy? That's a very good question. I think it would help definitely the management of diabetes and potentially the progression of neuropathy, but I don't know that different degrees of neuropathy will be reversed. So that's probably one that I would work with a neurologist or an endocrinologist to say, what type of neuropathy is this? Is it pressure related to the nerve or is this true diabetic changes that are not gonna be reversed? So there's definitely chronic disease, I think with obesity that will not be reversed. An example would be arthritis and we have that conversation with patients. We may not be able to reverse certain types of damage, but we're definitely gonna be able to prevent further damage. And if we get them to a place where they need an intervention, they're gonna be in a safer place. So I think certain types of neuropathy, especially peripheral neuropathy and small vessel disease that you see with diabetics may not be able to reverse, but that doesn't mean it's not important to intervene in a therapy that's gonna help to treat the underlying disease. And I actually have a question for you as well. What do you recommend for your patients after having bariatric surgery? Like how long to wait after that and how much weight loss before they pursue elective surgery like with? So, sometimes timing is really important to patients. Like they need a knee replacement or we're talking about fertility and the risk of losing that window of fertility or becoming to a higher age. So in some circumstances where we're talking about timing and we want the maximum amount of weight loss, we may actually choose an operation like gastric bypass, which is gonna work by two mechanisms and work a little bit quicker. Where most patients are gonna lose a majority of that weight within about 18 months. And that happens fairly consistently. A sleeve may take about two years to three years. So it sort of depends on the circumstance about timing. As far as other procedures, again, depends on the procedure. Somebody who needs a back surgery or a knee replacement or even pelvic floor surgery, it may be more beneficial to reach that maximum amount of weight loss or that plateau before they go for another surgery. So if it can be delayed or if we can see if there can be improvement in function like urinary incontinence or probably not prolapse because once that happens, I think that's not gonna be reversed, but urinary incontinence may be reversed with weight loss before we intervene. That might be worth waiting until we get to that plateau. So I think that conversation happens openly between subspecialists. And that's where I would probably talk to you, come up with a plan and we would counsel the patient in a joint way. I think that's a great way to do it. That's great, thank you. Yep. Any major surgery, I might wait about three months. So any surgery that can be semi-elective or major surgery, I would probably wait at least three months for just the overall risk of DVT and things like that. But I think if we can delay it six months a year, I think that would be ideal. That's great, thank you. Okay, I don't see any further questions coming up. So on behalf of the Oggs group, I'd like to thank Dr. Patel and everyone for joining us today. Our next FBMRS webinar will be held on Wednesday, June 16th at 7 p.m. Eastern time. Visit the Oggs website to sign up. Thank you and everyone and good night. Thank you again. Thank you. Thank you. Thank you.

Health Services Research

FBMRS

webinar presentation

Dr. Roy Patel

Dr. Kimmy Minhaji

obesity prevalence

causes of obesity

genetics and environment

pelvic floor disorders

bariatric surgery

comprehensive approach to obesity care