Where is it a problem?

• It’s currently mainly a problem in India and Pakistan.

Will is spread to other regions?
Probably. It’s easy for people to travel around the world quickly, and it’s easy for new microorganisms to travel with them. A bug that originates in one region can very easily spread across the planet. NDM-1 has been found in a few other countries, including Australia, parts of Europe and Canada. There is concern that the increase in health tourism (traveling to countries like India for cheap and quick procedures like elective surgeries) will result in spread of NDM-1, since people could pick up the bug in hospitals and bring them home. Transmission of NDM-1 in hospitals from patients that had healthcare procedures abroad has been documented in the UK. People traveling to regions where the organism is present for other reasons are also possible sources.

Consultant laparoscopic and bariatric surgeon David Kerrigan, the Royal College of Surgeons’ representative who advised the government on the NICE obesity guidelines in use today, said the lack of follow up care provided by some hospitals was ‘shocking’ and could put patients’ lives at risk.

“I have long been concerned about hospitals who in effect abandon patients after surgery to keep costs down and make a bigger margin then just turn a blind eye when things go wrong,” said Mr Kerrigan, former secretary and founder member of the British Obesity Surgery Society.

“It takes a great deal of money and commitment to put the resources in place to allow patients 24/7 access to the surgeon and his team and provide specialist medical advice at every step of the way following bariatric surgery.

“What I strongly object to is the way in which certain private hospitals offer surgery on the cheap at the expense of the aftercare and the patients never see the surgeon again.

“In my opinion, it’s absolutely vital that the surgeon who operated is directly involved in the patient’s aftercare. Some hospitals simply have an advisor or a nurse at the end of the phone and it’s just not acceptable.

“Patients often think they’re getting a good deal but sadly cut-price weight loss surgery generally means cut-down care,” adds Mr Kerrigan, who is also medical director of Gravitas, a network of weight loss surgeons in the UK and Ireland committed to working to the highest ethical and professional standards in bariatric surgery.

“Patients need to be cautioned strongly about what they are letting themselves in for. Adequate medically supervised aftercare is essential to ensure that they receive not just a good result, but a safe one.”

As Mr Kerrigan points out, this is particularly critical with gastric banding**. “What patients often don’t realise is that follow up care is absolutely crucial to getting the result they want.

“Sometimes complications can set in months or even years after the operation is performed and need to be picked up quickly under the ongoing care of a surgeon who can deal with a problem at the drop of a hat. If they are not, the patient could be seriously at risk.

“The trouble is, if complications develop and a patient can’t get easy access to a specialist surgeon, it’s often left to the NHS or the local GP to pick up the pieces. Patients may well end up seeing a non specialist who has no idea what to do. It’s a dreadful state of affairs.”

Mr Kerrigan said he was concerned too about the worrying number of reports filtering through about certain private hospitals who bend the NICE guidelines by operating on ‘desperate’ patients with a body mass index (BMI) of less than 35 who do not meet the criteria as they are too light for surgery.

“It’s professionally and ethically wrong for private hospitals to perform specialist surgery outside the NICE guidelines for what can only be described as pure financial gain,” he said.

“Although this has been happening in Europe for a while, it’s disturbing that it now seems to be occurring in the UK too. Bariatric surgery should never be carried out just because a patient is desperate to lose a bit of weight for cosmetic reasons,” he said.

“This type of specialist surgery should not be undertaken lightly. Although it’s an extremely effective and valuable treatment in heavier patients, in lighter ones it’s like taking a sledgehammer to crack a nut.”

Mr Kerrigan added that successful weight loss is very dependent on the strength of the partnership patients develop with their surgeon and his or her team.

“They will need the surgeon’s help long after their operation has been performed if they are to get the most out of it,” he said. “Sadly, not all weight loss surgery providers are willing to make this commitment to their patients.

“The sad truth for many patients is that they don’t realise when they are being sold cut-price surgery that they will not be receiving the complete package of care necessary to maximise the chances of a safe and successful outcome.” ENDS

*weight loss

** An effective weight loss surgery procedure used to help overweight people achieve significant and long-term weight loss.

About David Kerrigan

MD with Distinction (1992), FRCS, FRCSEd (1986), MBChB (1982)

Honorary senior lecturer in surgery at the University of Liverpool, Mr Kerrigan practises at the Spire Murrayfield Hospital, Wirral and is amongst the elite of UK bariatric surgeons. He is medical director of Gravitas, which has created a pioneering network of doctors and surgeons in the UK and Ireland committed to working to the highest ethical and professional standards in bariatric surgery. Awarded the prestigious ‘team of the year’ accolade for innovative surgical practice by the independent Association for the Study of Obesity in 2009, Gravitas treats both private and NHS patients and has helped train many bariatric surgeons in the UK through its fellowship programme for senior surgical trainees. Widely respected by both the public and his surgical peers for his technical skill and commitment to uncompromisingly high standards of bariatric care and aftercare, David Kerrigan is a pioneer of laparoscopic (keyhole) bariatric surgery in the UK and has lectured widely on this subject both here and abroad. His work has been featured in numerous television and newspaper reports.

What to look for in a weight loss programme

• Are staff qualified?
• Does the weight loss programme have a proven track record?
• If you choose to undertake weight loss surgery such as a gastric band or gastric balloon is an aftercare programme provided?

Patients on the Gateway Health weight loss programme lose, on average, more than twice the percentage of excess weight when compared to other published studies. All staff and surgeons working with Gateway Health are leaders in the field.

Follow the gastric band patient diary of Michelle from Nottingham as she follows the Gateway Health programme Read More…..

It’s Official! The Gateway Weight Loss Management Programme produces World Leading results!

Patients on our programme lose, on average, more than twice the percentage of excess weight when compared to other published studies.
In a recent multi-centre study, patients on the Gateway Health weight loss programme achieved a much greater weight loss.

We always offer medical and surgical treatments as part of a proper programme of aftercare and support, this ensures that patients can confidently make the lifestyle changes to achieve their health goals.

At Gateway Health we understand the value of a safe exercise programme.

Benefits are evident in both the initial stages after your surgery and long term in helping you to achieve and maintain your weight loss and health goals.

We strongly recommend using an exercise coach to ensure safe and progressive programming tailored to your health needs.

We have a friendly and emphatic approach along with a great understanding of your current health to enable us to support and progress your exercise at a pace that you can enjoy.

Gateway Health is proud to announce the latest member to join our staff team:

Dale Staton :

BSc Honours degree in coaching, sport and exercise science.

Qualified personal trainer and sport massage therapist.

Qualified stress management consultant.

GP Referral Qualification – enabling Dale to achieve fitness goals with those unfortunate to suffer with chronic conditions and perhaps nervous to start training.

Dale provides personalized and progressive exercise programmes to meet lifestyle/wellbeing goals which can be maintained for a lifetime.

Dale uses his knowledge and determined character to provide an outstanding aftercare support to Gateway Health patients to get the results you deserve.

If you would like to take advantage of Dale’s expertise please call:

0845 9000 339 for more information.

“While surgeons have always understood the importance of follow-up care, this survey helps quantify how much of a difference it really makes,” said Scott Shikora, MD, ASMBS President and Chief of General Surgery, Bariatric Surgery and Minimally Invasive Surgery at Tufts Medical Center in Boston. “Compliance can mean the difference between a good result and a great result.”

Surgeons typically recommend post-surgical activities including regular exercise, nutritional counseling, maintaining a food diary, psychological counseling, diet modification, keeping doctor’s appointments and participation in support groups. However, 66 percent of surgeons believe there is no consensus on what constitutes bariatric surgery follow-up care. About half (48%) say they did not receive bariatric surgery follow-up care education as part of their training or fellowship.

Surgeons believe regular exercise (67%), changing eating habits (58%) and support group attendance (34%) are the most difficult components of aftercare for patients and that while both groups of patients face compliance challenges after surgery, gastric band patients have a more difficult time with it than gastric bypass patients (59% vs. 49%). In addition, surgeons indicate that missed doctor appointments, insurance issues and long-distance travel are the reasons they do not see their patients more often.

“Techniques in bariatric surgery are consistent, but follow-up care tends to vary from bariatric program to bariatric program,” said Alan Wittgrove, MD, a past president of the ASMBS and medical director of the Wittgrove Bariatric Center and Scripps Memorial Hospital in La Jolla. “There are a lot of good programs out there but there is a need to standardize follow-up care so patients can achieve the best outcomes possible.”

Gastric band patients who participated in five or more components of aftercare lost 30 percent more weight and reported having a significantly better quality of life than gastric band patients who participated in four or less. Compliant gastric bypass patients also lost more weight than their less compliant counterparts, but their success was not linked to any specific number of post-surgical activities. Gastric bypass patients (77%) indicated greater ease in complying with doctor recommendations than gastric band patients (66%).

It’s not only what patients and surgeons do after surgery that can determine success. The vast majority of surgeons have patients engage in educational activities, nutritional counseling, medically supervised diet and exercise programs, support groups, and goal setting prior to surgery. Patients who felt prepared were twice as likely (39% vs. 18%) to say compliance after surgery was easy than those who felt “very or somewhat” unprepared for surgery. Surgeons believe commitment to diet, exercise and making lifestyle changes are the most important factors that patients should know about to succeed after surgery.

According to the survey, surgeons believe patients choose gastric bypass over gastric banding because it results in more weight loss (51%), they knew someone who had it (40%), to lose weight more quickly (34%) and for “better comorbidity resolution” (23%). They say patients choose gastric banding over bypass because it’s less invasive (63%), safer (59%), reversible (55%), results in fewer complications (41%) and because they knew someone who had it (25%).

Life Before Surgery
On average, patients tried 24 diets and exercise programs before surgery and have been obese for about 20 years. Two-thirds (67%) of patients reported having an average of five obesity-related conditions. They considered bariatric surgery for about three years before deciding to have surgery and about one-quarter of them were denied insurance coverage about three times before getting approval. About 60 percent of patients report that their health worsened during this waiting period. Improving their health (25%), losing weight (20%) and resolving disease (17%) were top reasons patients opted for bariatric surgery while only 3 percent said they wanted surgery for cosmetic reasons. Almost three times as many patients thought they were more likely to die from obesity (64%) than from bariatric surgery (24%).

Surgeons say most patients come on their own accord (44%) or are referred from a primary care practitioner (36%). Most patients come to the surgeon requesting a specific type of procedure (68%).

Gateway Health Comment
All of the previous paragraphs discuss surgeon attitudes to weight loss and bariatric patients. At Gateway Health, we agree with the vast majority of what has been discused, however we feel a more balanced approach is provided by a team. That team approach includes surgeon input as well as the input of specialist surgical nurses, specialist psychiatric nurses, bariatric dieticians, behavioural psychologists and sports coaches. The dynamics of this team, allows for many different medical approaches to the same problems. This produces results that show over twice the excess weight loss of similar studies*.

About the Surveys
Online surveys were conducted in April and May 2008 among 282 surgeons and 409 patients (208 gastric bypass surgery patients and 201 gastric band surgery patients).

Bariatric and general surgeons who performed bariatric surgery for at least three years, and at least 100 surgeries during their career were recruited from the ASMBS, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), and Harris Interactive’s Physician Panel and the American Medical Association (AMA) master file. Patients who had gastric bypass or gastric banding surgery in the previous one to five years were recruited from Harris Interactive’s Chronic Illness Panel, general population panel and eRewards Patient data were weighted to be representative of U.S. obese adults ages 18 and older. Propensity score weighting was also used to adjust for respondents’ propensity to be online. Because the sample is based on those who agreed to participate in the online survey, no estimates of theoretical sampling error can be calculated. A full methodology is available.

The survey sponsor, Ethicon Endo-Surgery, a Johnson & Johnson company, develops and markets advanced medical devices for minimally invasive and open surgical procedures, focusing on procedure-enabling devices for the interventional diagnosis and treatment of conditions in general and bariatric surgery, as well as gastrointestinal health, gynecology and surgical oncology.

*In a recent study, patients of Gateway health showed an average of 73.5% excess weight loss in the first 6 months. Previous similar studies show between 30-33% excess weight loss over the same period.

Nicholas Rudd-Jones talked to Mr Alfred Choy MA MB BChir FRCS and Mr Andrew Kemp RGN, MSc, DMS the CEO of Gateway and president of the National Institute of Obesity Programme Practice Standards (NIOPPS) to understand the Fitzwilliam’s radical new ‘Gateway pathway’ to weight management which is based around the belief that continuing weight management support is a vital part of a successful long-term outcome

The problem of obesity
Obesity is an increasing problem in our society with the ready availability of fatty foods and a more sedate lifestyle. And obesity, if untreated, can lead to various medical problems including heart disease, respiratory problems and diabetes, all leading to reduced life expectancy. Obesity is calculated by the Body Mass Index (BMI):. 20-25 is normal, 30 or more is obese and 40 and above is morbidly obese.

Weight management
The first step in losing weight is to diet and take more exercise, but normally a diet leads to fairly modest and temporary reductions in weight, typically 5-10%. Likewise, there are drug treatments that can lead to a similar reduction in weight.

Gastric banding, which is the insertion of a restricting band around the stomach that limits what a patient can eat, so they lose weight, can have a much more profound impact on body weight, typically reducing the body weight by 30-70%. The National Institute for Clinical Excellence (NICE) guidelines indicate that you are eligible for the treatment if you have a BMI higher than

40 or 35 if you have an additional condition such as diabetes or asthma. The procedure itself is done by keyhole surgery and the operation itself takes about an hour. Including preparation and recovery time, you are likely to be in hospital for two days.

Ballooning, which does not require an anaesthetic and is a totally reversible process, works by inserting a ‘balloon’ within the stomach to reduce hunger; it can likewise lead to significant weight reductions and may be a good solution in certain circumstances. The Gastric balloon procedure is a non surgical procedure, the balloon remains in the stomach for 6 months. It is an effective solution for some patients from BMI 27. The balloon reduces hunger and allows the patient to make lifestyle changes with the help of the Gateway Lifestyle Programme.

The Gateway pathway
The Fitzwilliam has observed that, whilst a surgical intervention may be the best way to lose weight, its effectiveness is sharply improved by working together with the patient from the start of the process through to 12 months and more after, to ensure that the right weight management habits are formed and then maintained. In the words of Andy Kemp, who runs the Gateway pathway, “continuing support is a vital part of the process”. Without this support, there is a danger that a patient might ‘cheat’ the weight loss device and start to put on weight again at a later date.

How does the Gateway pathway work?
The Gateway pathway, in a nutshell, brings all aspects of care together – the quality caring environment of the Fitzwilliam Hospital, the clinical excellence of the consultants and the Gateway pathway methodology that manages the patient’s progress throughout the process.

The Gatewayhealth ‘pathway falls into five broad steps:

Step 1
The patient can approach the Fitzwilliam through a GP referral or directly. They will meet with a qualified nurse and complete a detailed questionnaire so that the hospital can fully understand the behavioural and physical issues around their situation.

Step 2
If appropriate, the patient will then be referred to Mr Choy, the consultant in charge. He will assess the individual’s case and determine whether surgery is the most appropriate route, and if so whether that should be gastric banding or ballooning.

Step 3
The patient is prepared for surgery by a specialist nurse and a consultant anaesthetist. After a gastric banding operation they will usually stay overnight and leave the next day.

Step 4
The patient is contacted daily for the next two weeks by a named specialist nurse to ensure that everything is progressing smoothly and that good weight management habits are becoming established. The patient is called for the first few days and longer as necessary, the patient has a direct contact number for their nurse and is seen in clinic at week one. There may be a return to the hospital clinic after a couple of weeks for the band adjustments as required.

Step 5
It is reckoned that new habits typically take three months to form. This is vital to ensuring on-going weight loss and the named contact will continue to provide support to the patient to help them to become self-sufficient in any social.

In summary, the Gateway pathway brings together a team of professionals who act seamlessly throughout the process, bringing all aspects of the care together, to produce the best possible outcome for the patient. And critically the patient remains the main focus throughout the process

The consultant at the Fitzwilliam
Mr Choy is a Consultant Physician in General Surgery at the Fitzwilliam. He trained in Cambridge, Liverpool and London. About fiveyears ago he went to Brussels to gain specific expertise in gastric banding, and he is a member of the British Obesity Surgery Society (BOSS). He is supported by a second specialist, Mr Bajwa. Mr Kemp leads the Gateway pathway ensuring that the overall process is optimised, and supplying the pre- and post-op support.

Next steps

Call Gatewayhealth on 0845 9000 339

A new scoring system that rates a gastric band surgery patient’s risk of complications on a scale of 1 to 4 can help reduce post-surgical complications by 65 percent and hospital readmission rates by more than 80 percent, according to a new study presented today at the 26th Annual Meeting of the American Society for Metabolic & Bariatric Surgery (ASMBS).

Researchers from Arizona devised a Metabolic Acuity Score (MAS) that places surgery patients into one of four groups based on risk factors including the severity of their morbid obesity and obesity-related diseases such as Type 2 diabetes, sleep apnea and heart disease, and their psychological health.

The study found that after MAS had been implemented, 30 day post-surgery complication rates dropped by 65 percent, from 17.9 percent to 6.2 percent, which is significantly lower than the 15 percent inpatient complication rate reported by the Agency for Healthcare Research and Quality (AHRQ) for bariatric surgery. Thirty-day hospital readmissions fell 81 percent from 7.4 percent to 1.4 percent, lower than the 7 percent rate reported by AHRQ. On average, patients lost almost 80 percent of their excess weight within one year and the mortality rate was zero.

“Using the Metabolic Acuity Score (MAS) as a risk management system improves the safety profile of gastric band surgery to levels approaching routine gallbladder surgery, even for high risk patients,” said Robin Blackstone, MD, FACS, lead study author and bariatric surgeon at Scottsdale Bariatric Center in Arizona. “With significantly reduced complications and hospital readmission rates, we are improving patient care and lowering costs at the same time for patients suffering from life-threatening diseases.”

595 laparoscopic gastric band patients were evaluated for incidence of major complications, mortality, length of hospital stay, readmission and re-operations. Dr. Blackstone performed each of the surgeries at a community hospital in Scottsdale between 2001 and 2008. The analysis compared patient complications before and after MAS was instituted with 1,072 patients beginning in August 2006. A MAS score of 1 represents the least at risk and a score of 4 represents patients at highest risk for complications.

Patients in the highest risk groups were more aggressively managed before and after gastric band surgery for obesity-related diseases with medical treatment, psychological counselling, and careful monitoring by a multi-disciplinary health care professional team.

The adjustable gastric band group experienced significantly fewer band slips (6.7% vs. 0.6%) and had a reduced hospital stay (1.3 days to 0.8 days).

“This risk management system shows that if we know and better prepare for the individual risks specific patients face before and after surgery we can make a relatively safe procedure even safer, more personalized and more cost effective,” said Dr. Blackstone.