On this Bariatric Friday, Kemal Erkan, Chairman of American Surgery Center and CEO of Christiana Institute of Advanced Surgery (CHRIAS), is joined by Dr. Isaias Irgau, President of CHRIAS with a specialization in weight loss surgery, to participate in a discussion regarding care coordination.

Dr. Irgau begins by defining bariatric surgery, “bariatric surgery is a surgery that is performed to help people lose a substantial amount of weight… a person’s weight has to be at least one hundred pounds over their ideal weight to qualify for bariatric surgery”. Another way to be a suitable candidate for bariatric surgery is to have a body mass index (BMI) of at least forty or at least thirty-five if the person also has certain illnesses such as type 2 diabetes, sleep apnea, or high blood pressure.

The two are continuing to discuss the journey of Katrina and Samantha, both of whom were referenced in a few previous Bariatric Friday discussions. Katrina is thirty-seven years old with a BMI of forty-seven, and she decided to undergo the procedure of a gastric sleeve. Samantha is sixty-two years old and has sleep apnea, heartburn, and diabetes so she chose gastric bypass surgery. “Both Samantha and Katrina have struggled with weight for a very long period of time; they have tried all diets known and not succeeded… once both Katrina and Samantha decided on bariatric surgery, they expected to have the surgery the next day, the next week… as soon as possible,” Dr. Irgau explains, “this is not treated like any other surgery… there is an extensive preparation period that requires the input of different specialists”. This is to prepare them for success in their weight loss journey. There are steps in place that a patient must complete before receiving bariatric surgery that include: Meeting with a dietitian, having scheduled appointments with a psychologist, cardiologist, pulmonologist and obtaining tests such as an endoscopy, blood work, sleep study and a chest x-ray. Uncovering and addressing Samantha and Katrina’s problems prior to surgery will ensure they undergo the surgery safely. If the patient were to navigate this all on their own, it would be overwhelming and not done in a timely fashion; however, CHRIAS helps their patients throughout this process with appropriate evaluations and education. Communication between the patient and the doctor is the key to a successful weight loss journey both preoperatively and postoperatively.

When the surgeon deems a patient acceptable for surgery, a bariatric care coordinator is assigned to the patient. The care coordinator will then be the point of contact throughout the entirety of the bariatric process, making sure the patient meets all the requirements needed before surgery. There is open communication, and the patient is continually supported throughout their journey. The patient already faces many challenges, so it is important to make the process as easy as possible for the patient. Erkan mentions the new emails that they are sending to patients, and he asks Dr. Irgau if he has received any feedback regarding the communications. “Patients really appreciate that because it gives them a way to stay in touch with the office without having to call the office on the phone or be on hold… when they have a bariatric coordinator… it makes it a lot easier… it’s a super VIP treatment,” Dr. Irgau explains. The patients deserve this ease to properly navigate this pre-procedure journey. Life is busy for every individual, so having this one-on-one guidance is imperative to staying on track. “The fact that we have the bariatric coordinating nurses follow with the patient… really helps the patients stay on course, and it helps us as bariatric surgeons also to have patients that are not only well prepared, but they are also comfortable with the process,” Dr. Irgau states. The patient should start the process with confidence, not by losing faith.

One of the most important tests bariatric patients undergo before surgery is a sleep study. This is to assess whether the patient has sleep apnea, which is when the soft tissue in the back of the throat airway causes blockage and interferes with the ability to breathe during sleep. Symptoms of sleep apnea include restless sleep, fatigue, snoring and waking up suddenly after gasping or choking. When a diagnosis of sleep apnea is confirmed, a continuous positive airway pressure (CPAP) machine is prescribed, which helps keep the upper airway passages open to stop apnea. This is particularly important when preparing a patient for surgery. “Bariatric surgery is the ultimate treatment for the vast majority of patients who have sleep apnea,” Dr. Irgau mentions, “it is important that they go through anesthesia for bariatric surgery… we have to educate our patients to make them understand how important this is, so getting the CPAP machine, going through the process is challenging, but it is critical for their safety”. Guidance from the bariatric coordinator is crucial to help navigate all the steps for this condition because it can be incredibly challenging for the patient if left to do it alone.

Sometimes unexpected issues arise throughout the preoperative journey. Early detection of these concerns is important so the patient can address them sooner rather than later. “Frequent interaction with the patients has two important advantages, both for the surgeon and for the patient,” Dr. Irgau says, “the first one is that we are able to really follow through on what is missing in their progression but also address certain issues that may come up when they have these evaluations.” When there is open communication, the patient and the doctor together can develop a course of action that is in the best interest of the patient. This immensely improves the quality of the preoperative process.

“By 2030, one in two adults in the United States is projected to have obesity… and one in four is projected to have class 2 or class 3 BMI over thirty-five… knowing that this disease is so costly and impacting people's lives, we need to make sure this process is pleasant enough, so that they do not drop from the program” Erkan states. He continues, “the care coordination is important from that point, and we want Katrina and Samantha to be happy and healthy”. Dr. Irgau proclaims “as a bariatric surgeon, I could not be more proud to be practicing in this setting where we are preparing our patients so well that it’s almost flawless in terms of how the whole process goes through, and I can tell you, hearing the comments of the anesthesiologists… whom the patients meet on the last day… these patients are prepared so well”. Erkan closes with, “preparation is the most important part of long-term success, and I am glad that we are able to do that and able to touch many people’s lives”.