Like many other fields in medicine, bariatric surgery specialists have had to rely on telemedicine during the pandemic to minimize risk for health care providers and patients. At Penn Medicine, providers say that use of technology has made appointments more accessible, and may be partially behind an increased demand for new patient appointments and long-term follow up appointments compared with pre-pandemic times.
“I think there is an awareness across the country and the world actually in relation to obesity and COVID-19, and this has increased the interest of patients who are morbidly obese in wanting to get bariatric surgery,” said Noel N. Williams, MD, director of the Penn Metabolic & Bariatric Surgery Program. “Being able to get these patients into our system easier than them physically having to travel for an appointment at the hospital has been a game-changer.”
For those thinking about weight loss surgery, one of the first questions they may ask is about what the requirements are for patients to qualify. Bariatric Program Manager Colleen Rauchut Tewksbury, PhD, MPH, RD, said the first requirement is meeting weight criteria, which she says about one in every 10 adults in the United States already does.
From there, the preoperative process typically starts with a patient attending an information session and an initial consult, where a dietitian takes a detailed dietary history, and a nurse practitioner goes through the person’s entire medical history to ensure the patient is ready for the procedure and lifestyle change it brings. Then, the patient would complete anywhere from three to six months of preoperative counseling, depending on requirements from their insurance. Insurance may also require providers to screen for conditions like undiagnosed diabetes. At Penn Medicine, Williams’ team works closely with the Center for Weight and Eating Disorders in the department of Psychiatry to connect patients to the care they need during this process.
“We commonly see internalized weight stigma as a barrier to seeking bariatric surgery. Many people have this perception that obesity is a personal problem that can be solved solely through behavior change. But obesity is a metabolic disease, not a behavioral disease, and therefore often requires a metabolic treatment like surgery,” Tewksbury said.
When a patient starts this counseling process before bariatric surgery, they will meet with a psychologist who is an expert in weight management behavioral evaluation. They will help the patient answer whether they are truly ready for surgery, and it’s not a pass/fail situation. If the person would like to explore surgery, but doesn’t feel quite ready, the psychologist can help identify what additional support a person can get to.
“I think the major misconceptions are that this is a very dangerous procedure across the board. This is actually not correct,” Williams said. “Many patients who come to see us have many comorbidities or other illnesses like sleep apnea, high blood pressure. And people feel that because they have these, they're not going to be safe candidates for surgery. However, this is not necessarily true. When we see new patients, we assess them very carefully to make sure that any medical conditions that they have that we need to improve on before surgery, we do so to make it a safe operation.”
At Penn Medicine, surgeons either perform a sleeve gastrectomy or a gastric bypass. Both of these are done in a minimally invasive fashion using a robotic approach. The sleeve gastrectomy is the most common kind of bariatric surgery, and it’s where the surgeon takes away up to 75 percent of the stomach to make it smaller, leaving the patient with a decreased desire to eat, and ability to eat large amounts of food.
For a gastric bypass, surgeons make a small pouch in the stomach and then bring a loop of intestine up to bypass the stomach itself, leading to a decrease in the amount of food a person can eat, and resulting in malabsorptive operation, where the nutrients are absorbed later or further down in the gastrointestinal tract. Less nutrients coming in means more weight loss for the patient.
Lastly, Williams said patients should be ready to be treated as a whole person, rather than just focusing on the surgery. "This is really a multidisciplinary group,” he said.
At Penn Medicine, the Bariatric program collaborates closely with gastrointestinal physicians, the Penn Medicine Metabolic Medicine Group, even cardiac and pulmonary physicians to work through other conditions prior to surgery. While most programs refer out or have very limited resources, Penn Medicine has large multidisciplinary, subspecialty team under the same roof. For example, most programs in the region refer out to a specific dietitian, or if they do have a team one, they’re part time. Penn Medicine has eight dietitians dedicated specifically to the bariatric program.
“Our clinicians are not general practitioners; they are specific experts in bariatric surgery,” Tewksbury said.
Up next on the Penn Medicine News Blog: learn more about the realities of bariatric surgery in the final post from this two-part series.
If you or someone you know is interested in learning more, visit the Penn Bariatric and Weight Loss Surgery website or register for a free online information session.