Patient Interview - Rod has lost 105 lbs in 7 months

      Stacie talks about using a heart monitor to optimize exercise

      Dr. Sewell talks about the latest technology called TNE

      Patient interview with Laura who has lost 80 pound 6 years after Lap Band

      Sandi discussed the book "Food Rules: An Eaters Manual" by Michael Pollan

      Patient Interview - David has lost 78 lbs in 6 months

      Sandi talks about Breakfast Ideas

      Stacie discusses ways to stay motivated

      Dr. Sewell talks about Goal Setting

Over the last 30 years things have changed significantly. The incidence of adenocarcinoma has been rising steadily, to the point where today this type of cancer now accounts for the majority of esophageal malignancies. A number of theories have been suggested as to why this dramatic change has occurred, but there is no proof as to the actual cause. We know that unlike squamous cell cancers these tumors are more common in caucasian men who have chronic symptoms of acid reflux. Repeated acid injury is well known to be associated with the development of a condition known as Barrett’s esophagus, where the esophageal lining changes into tissue that looks more like the lining of the stomach. These abnormal areas of mucosa are at further risk for undergoing additional changes that can culminate in adenocarcinoma. Although the incidence of Barrett’s esophagus is still relatively low in the population in general, it has been steadily rising and along with it the risk of this type of cancer.  

The presence of Barrett’s changes can only be determined by inspecting the inside of the esophagus with an endoscope. This procedure is commonly referred to by one of several different name: upper GI endoscopy, esophagogastroduodenoscopy, EGD, or sometimes just a scope. During the procedure biopsies can be taken of any suspicious appearing tissues, and if Barrett’s is confirmed appropriate treatment is then recommended. There are some promising new endoscopic treatments available to treat Barrett’s, but in general the primary way to manage the problem is to aggressively control the reflux of acid from the stomach up into the esophagus. This can be accomplished either with daily medications that suppress stomach acid production, or by performing a surgical procedure to improve the function of the failed anti-reflux barrier between the stomach and esophagus. 

Unfortunately, esophageal cancer has few if any early symptoms, but as it progresses patients typically complain of increasing difficulty swallowing. These malignancies are extremely difficult to treat successfully unless they are diagnosed very early, long before there are any symptoms. The most effective treatment is often the surgical removal of the esophagus, an extremely challenging and potentially disabling procedure. Radiation and chemotherapy can also be used to treat patients with esophageal cancers, but once again, a successful outcome depends largely on making an early diagnosis. 

So what’s the bottom-line? If you suffer from chronic heartburn, even if its reasonably well controlled with either prescription medications or over the counter drugs, you should, at some point, have an endoscopic examination to check for Barrett’s esophagus. This is especially true if you are a caucasian man over the age of 50, but actually anyone who has chronic reflux is at risk. Esophageal cancer is largely preventable, and controlling your acid reflux is the single most important thing you can do to protect yourself. As you’ve heard on countless television ads for the various acid reflux medications, it could be something more than just a little heartburn. If you have any questions about Barrett’s or esophageal cancer consult your doctor.

      Patient Interview - Lindsey has lost 92 lbs in 7 months

      Sandi talks about "getting through Thanksgiving"

      Dr. Sewell was on BlogTalkRadio/Weight Loss Surgery 

The reason I was asked to be on this panel was the fact that several years ago I co-authored a book on weight loss surgery with one of my patients, Linda Rohrbaugh, who was also a guest on the program. Our book is titled “Weight Loss Surgery with the Adjustable Gastric Band – Everything You Need To Know Before and After Surgery To Lose Weight Successfully.” While this is the title we agreed on after discussions with the publisher, it is not the one Linda and I used to submit the manuscript. Our preference was “Stepping Out of the Shadow of Obesity – A Comprehensive Guide to the Adjustable Gastric Band.” At least for me this said it all, and the word “surgery” was not in the title anywhere.

 Anyone who has struggled with their weight for years understands the concept of living beneath their own shadow. For these patients, their size and weight impacts virtually every aspect of their day to day lives, physically, socially, economically, emotionally and even spiritually. I have had countless patients try in vain to explain their frustration with their inability to conquer this problem despite repeated diets and countless trips to the gym. What they, and many of my medical colleagues, often fail to recognize is that obesity is a disease. But unlike virtually every other disease, this one carries a stigma of personal failure.

Whether they say it or not, many physicians blame their patients and expect them to fix the problem themselves with diet and exercise. This is despite a National Institutes of Health White Paper published 20 years ago on the growing obesity epidemic in America. The NIH conclusion was that morbidly obese patients have only a one in twenty likelihood of losing weight and keeping it off with diet and exercise alone. I don’t know of any medical or surgical treatment that would be offered to anyone if the chances of success were measured in single digit percentages, yet Americans spend more than one-hundred billion dollars annually on diets and exercise programs, and we keep getting fatter as a nation.

While weight loss surgery is not right for everyone, and there is no single procedure that is clearly superior in all cases, the fact is that when combined with a comprehensive weight management program it can be life changing for many patients. The key is getting everyone, including the entire medical team as well as immediate family members, committed to the patient’s success. This starts with making sure the patient is completely informed about everything from the preoperative diet to possible surgical complications. Surgery merely provides them with a tool that they must learn to use to change their lifestyle habits.

But from my perspective the element that is most often overlooked involves getting the patient actively involved in developing their own realistic goals and expectations, including acknowledging what they must do to achieve them. When patients are required to accept personal responsibility for this part of their program, a process of personal empowerment begins.

I tell every patient the same thing. Obesity is not your fault, BUT, it is your responsibility. In the end, only those patients who are willing to accept the responsibility to do whatever it takes to regain control of their lives and their health are likely to succeed long term. So, back to the original question, is weight loss surgery right for you? The answer depends on your willingness to actively step out of the shadow of your obesity.

Robert Sewell, M.D., F.A.C.S.

Read the November 2011 Newsletter

      Patient Interview - Michelle has lost 120 lbs - Gastric Sleeve

      Sandi discusses "My Life in France" by Julia Child

      Stacie talks about walking off those candy bars

      Dr. Sewell emphasizes consistent follow-up

Read the October 2011 Newsletter

      Patient Interview - Mitzi - Band to Sleeve Conversion

      Sandi gets into sugar

      Stacie talks about exercising at home

      Dr. Sewell discusses "Leading by Example"

Read the September 2011 Newsletter

      Patient Interview - Dr. O - Gastric Sleeve

      Dr. O gives the perspective of a GI Doc & Patient

      Sandi talks about "Hungry Girl Cookbook"

      Dr. Sewell discusses the American Obesity Epidemic

Read the August 2011 Newsletter

      Patient Interview - Jim lost 183 lbs - Gastric Sleeve

      Sandi discusses maintaining adequate hydration

      Stacie talks about workout accountability

      Dr. Sewell talks about reposibility of "Fox and Friends"

Read the July 2011 Newsletter

      Sandi presents High Protein Snacks

      Stacie works out with Bands

      Patient Interview - Charli - Gastric Sleeve

      Sandi goes shopping at Central Market

      Stacie offers special pricing at Purely for Fitness

      Dr. Sewell discusses "Falling Off the Lap-Band Wagon"

The title was actually decided on by the publisher and was designed to include every imaginable “keyword” that might be used to search the Internet for a book on gastric banding. I wasn’t exactly enamored with the title but accepted the wisdom of those who are in the business of selling books. I preferred the title I had used when submitting the manuscript, “Stepping out of the Shadow of Obesity – A Comprehensive Guide to the Adjustable Gastric Band.” To me, this spoke to what I believe is the heart of the issue of weight loss surgery; individuals taking the initiative to actively “step-out” from under the destructive effects of a lifetime of being over-weight.

At the time I wrote the book I was performing Lap-Band^® exclusively for my obese patients, because I believed it to be the safest option available. While I still believe the Lap-Band^® has a place in surgical weight management, over the last few years I have witnessed a number of long-term problems with the band. Chief among the complications is displacement or slippage. Over time the band can “slip” down on the stomach causing dilation and partial obstruction of the upper gastric pouch. This can occur despite the fact that the band is sutured in place. The telltale signs are chronic heartburn, chest pain, spontaneous regurgitation, failure to lose weight and even aspiration pneumonia.

When I first encountered the problem of a slipped band, I naturally believed the best treatment was to surgically reposition and re-suture it back in place. The results from these re-do procedures were acceptable, at least for a while, but several patients showed up with a second slip within a few months despite my best efforts. That’s when I decided to try something different, the gastric sleeve.  The sleeve was a very new procedure and involves removing about three quarters of the stomach pouch, but unlike the gastric by-pass there is no re-routing of the intestines. Around 2005 some of my colleagues had started to use the sleeve as a primary obesity operation, but I thought it made more sense as a “rescue procedure” for patients with a slipped Lap-Band^®.

I began converting patients with slipped bands to the gastric sleeve about four years ago and the results were truly amazing. Not only did the problems of heartburn, chest pain and regurgitation improve, these patients actually started losing weight again. It’s a well-known fact that most band patients lose about half of their excess weight and then just seem to hit a wall. But after conversion to the sleeve, many of my patients seemed to get back on track, losing up to 75 to 80% of their excess weight. Invariably they would tell me that the biggest difference they noticed was they weren’t hungry any more. The theory is hormones released from the stomach cause us to feel hungry, and since much of the stomach is physically removed during the gastric sleeve procedure, those hormones are also dramatically decreased. Without the constant feeling of hunger, gastric sleeve patients are better able to stick with their weight loss programs. In fact, most of my sleeve patients tell me they have to remind themselves when its time to eat. The sense of hunger does return after about six months, but never to the same degree they’d experienced before. Universally, my conversion patients tell me they wish they’d gone with the sleeve to start with. While hindsight is always 20/20, the fact is the gastric sleeve is still a relatively new option.

As a result of the success I saw in patients converting from the Lap-Band^® to the gastric sleeve, in early 2008 I started using the sleeve as the preferred option for most obese patients seeking weight loss surgery. Somewhat ironically this was about the same time my Lap-Band^® book came out in print. I’ve learned that writing a book, which takes a year or more to produce, is probably a waste of my time. So, given the fast paced world of Internet communication, I’ve decided to stick to writing this blog, which allows me to make changes “on the fly.” Currently, it is my opinion that the gastric sleeve, combined with a comprehensive weight management program, offers the best option for over-weight individuals interested in “Stepping Out of the Shadow of Obesity.” Its also the best option for those who have fallen off the Lap Band Wagon. 

As a surgeon I sat and watched the events unfold on television last Saturday and I was struck by how efficiently the emergency medical system responded to this major disaster. This was not some pre-rehearsed disaster drill, rather this was the real thing! On just another lazy Saturday morning I’m certain the emergency department at the University of Arizona Medical Center was in the process of seeing a few minor injuries, a couple of children with fever, and perhaps an elderly gentleman with chest pain. Suddenly, they were in the middle of what must have felt like a war zone. Helicopters and ambulances were arriving one after the other with critically injured patients including Congresswoman Gabriel Giffords. To describe such a scene as chaotic would be an understatement.

It’s truly remarkable how a civilian hospital and the personnel who work there were capable of shifting gears, becoming a major disaster management center in just a matter of minutes. It’s my understanding that 10 separate gunshot victims arrived at the University Medical Center, and all but one of them survived. The lone exception was nine-year-old Christina Green who had been shot in the chest. Regrettably, nothing could be done to reverse the mortal wound she suffered. As for the others, including representative Giffords, they were quickly and expertly transported into operating rooms where life-saving care was administered.

Over the last three and a half decades I have spent countless hours in hospital emergency departments caring for a variety of sick and injured patients including victims of trauma, and I can assure you that the remarkable actions of the trauma team in Tucson did not occur by accident. Trauma teams across the nation train regularly for such events and stand ready to deal with them whenever and wherever they may occur. So, if there is one thing positive that should come out of this tragedy, it is the realization that physicians and nurses and a variety of support personnel are ready and capable of dealing with even the most horrific acts of human violence or natural disaster. The results may not always be perfect, in fact sometimes an injury or illness is simply irreversible, but with God’s help the tireless efforts of dedicated individuals can, and often do, produce phenomenal results. 

One final point: Over the last several years the national discussion surrounding health care in the United States has consistently pointed to various statistics suggesting that we have less than quality care at a higher price than elsewhere in the world. Personally I reject that notion and would point to the events of January 8, 2011, in Tucson, Arizona as proof of the exceptional standards of American medicine.

The most powerful of the modern GERD drugs are known as proton pump inhibitors, or PPIs. They include Prilosec and Zegerid (Omeprazole), Protonix (Pantoprazole), Prevacid (Lanzoprazole), Aciphex (Rabeprazole), Nexium (Esomeprazole) and Dexilant (Dexlansoprazole). If you look at the generic names of each of these drugs they all end in prazole, referring to that chemical component responsible for stopping acid from being produced by the stomach. While some patients get better results from one than they do from another, the fact is they all work pretty much the same way. Interestingly it is not uncommon for one drug to work well for a period of time only to become ineffective. Changing to a different PPI may prove effective, assuming your insurance will pay for it; but that’s a whole different discussion.

For two decades the PPIs have been widely prescribed for both proven as well as merely suspected reflux. During that time there was little mention of potential side effects other than the fact that they occasionally cause cramping abdominal pain, diarrhea or constipation and excess gas, as well as a known interaction with the blood thinner Plavix®, But if you look more closely at the long-term effects of eliminating stomach acid there is a concern over what this does to Calcium absorption by the intestinal tract. Recently, the FDA reported on its review of a number of studies that demonstrated an increased risk of osteoporosis and pathologic fractures in patients who have been on PPI’s more than one year. This risk appears to be greatest in women over the age of 50 and increases with prolonged use of these medications. Calcium is simply not well absorbed when there is no acid in the stomach.

Certainly neither I nor the FDA are suggesting that everyone should stop taking PPIs; that is not at all practical. But if you are one of the millions of people who take medicine everydayfor heartburn you should know there are minimally invasive surgical procedures that can stop your reflux and thus the need for medications altogether. Perhaps the most exciting news in recent years has been the introduction of an incisionless surgery option for treating chronic reflux. The Transoral Incisionless Fundoplication (TIF procedure) can be used to strengthen the muscular valve between the esophagus and the stomach, and is performed entirely through the mouth, requiring no incisions. It is truly the definition of minimally invasive surgery.

While operations for reflux can provide some patients permanent relief from symptoms, they are not indicated for everyone. Prospective patients must first be properly evaluated, which includes an upper GI endoscopy to look for associated problems like hiatal hernia, esophageal stricture and other associated conditions. Additional tests may also be needed to not only prove the diagnosis of reflux, but also to help determine whether surgery is an appropriate alternative to a lifetime of pills.

If you’re interested in learning more about gastroesophageal reflux disease and its surgical treatment options go to www.robertsewellmd.com. There you’ll find videos explaining reflux as well as the available surgical options along with a number of patient testimonials. 

Over the years our lives tend to be measured, not only by annual holidays like Christmas, but also by other major events such as illnesses, injuries and major surgery. I can certainly testify to that fact in my own life and the lives of my wife and children. It is times of extreme stress as well as times of great joy that create permanent emotional imprints that define our lives. As a surgeon I feel privileged to have played a role in the lives of countless patients and their family members during such times over the past thirty plus years. Sometimes my role has been to provide healing and physical renewal while at other times it has been somewhat less pleasant. But in every case it has been my honor to serve with what talents God has given me. 

Today I received a Christmas card from one of my patients whom I haven’t seen for quite some time. His hand written note was very short but very meaningful to me. He simply said, “Thanks for the excellent healthcare that you have provided me over the years, I appreciate it. Merry Christmas.” I was truly moved by this simple, unsolicited note of thanks. It once again affirmed my belief that people are not as cynical and heartless as some would have us believe. Rather, the vast majority of people are kind-hearted, loving and willing to share the joys of life with one another. The problem is we don’t always get around to sharing our thoughts and feelings 

So, during this Christmas season I wanted to take a moment to say thank you to all who have allowed me the opportunity to participate in one of their major life events. I also want to wish all of you a joyous and peace-filled Christmas, and a happy, healthy and prosperous New Year.

For many people weight control is just a matter of eating smarter and getting a little exercise, but for those who need to lose more than 50 or 60 pounds such efforts often seem futile. The fact is the more weight you need to lose the more difficult it is. Whenever you go on a diet your metabolism slows down to compensate for the lower calorie intake. You lose 5 pounds and gain 10. The effects of “Yoyo dieting” make weight loss increasingly more difficult with each attempt.  The only way to increase your metabolism and the number of calories you burn is through regular exercise. Sounds easy enough, but when you factor in the pain of hauling those extra pounds onto the treadmill everyday, combined with a busy work schedule, exercise becomes something you’ll get around to, eventually.

So what’s the answer? First, we must approach obesity like the disease it is. People who have a serious weight problem frequently have associated health problems like diabetes, high blood pressure, high cholesterol, sleep apnea, acid reflux, arthritis and many others. Interestingly, most overweight people are on several medications to control these “co-morbidities” while the underlying problem goes untreated.

The National Institutes of Health produced a comprehensive “White Paper” on the subject of obesity nearly 20 years ago, just as this epidemic was emerging. They appropriately pointed out the futility of trying to deal with significant obesity using diet and exercise alone. Statistics suggest that fewer than 5% of people who are 100 pounds or more over weight are able to lose their excess weight on their own and keep it off. These facts have given rise to a growing trend in weight control, namely bariatric surgery. Over the last 15 to 20 years the idea of surgery to assist with weight loss has become increasingly accepted and many procedures have evolved that can provide safe and effective solutions. However, weight loss surgery must be seen for what it is, a tool to help patients develop an overall healthier lifestyle.

Surgery is typically thought of as the last resort for treating any medical problem, but once the decision is made to undergo an operation our expectations are that a successful operation will “cure” the problem. While this is certainly true for appendicitis, a sick gallbladder or a fractured hip, obesity is not like most surgical problems. The operation doesn’t cure the patient. Undergoing a weight loss procedure is more like getting a prescription that you have to take everyday. These procedures can restrict the amount of food you can eat, but they don’t control what you choose to put in your mouth. If you drink milkshakes or eat high calorie foods like chocolate, or drink two or three glasses of wine or a couple of margaritas everyday, you simply won’t lose weight no matter what operation you’ve had. Success requires commitment and discipline as well as some common sense.

The Gastric Sleeve procedure has become very popular in the last few years largely because it significantly reduces hunger, making it much easier to avoid the temptation to overindulge. But following this procedure most patients still need guidance, both from a trained dietitian to ensure they maintain proper nutrition, and some type of support program to keep them focused on attaining their goals.

For those who have already had weight loss surgery and either failed to lose weight or lost it only to gain it back, there is still hope. Many so-called “surgical failures” may still achieve the success they originally expected. Sometimes the answer involves more surgery, but sometimes it’s just a matter of getting the proper support. If that’s you, don’t give in to the temptation to give up. Perhaps your resolution for 2011 should be “If at first you don’t succeed, get another opinion.”

The Transoral Incisionless Fundoplication (TIF) procedure is performed entirely through the mouth using an innovative device called EsophyX2, which fits over a standard flexible endoscope. Using this device the surgeon can recreate a functional anti-reflux valve that keeps stomach acid from the sensitive lining of lower esophagus. This procedure represents the first in what promises to become an entirely new category of surgical procedures known as Natural Orifice Surgery (NOS). One can only image the possibilities as various operations that once required large pain incisions and lengthy recoveries becomes possible with no scars or pain. The future is filled with such dreams and it is exciting to be a part of this revolutionary process.

RESOLVED, That our American Medical Association immediately formulate legislation for an additional payment option in Medicare fee for service that allows patients and physicians to freely contract, without penalty to either party, for a fee that differs from the Medicare payment schedule and in a manner that does not forfeit benefits otherwise available to the patient. This legislative language shall be available to our AMA members no later than September 30, 2010.

The resolution passed by an overwhelming margin of 73% to 27% and is now official AMA policy. It is our opinion that the future of American healthcare can be ensured if we empower out patients by providing them with clear choices. Next week I will be traveling to Washington, DC along with several other co-sponsors of the resolution to work with AMA staff to finalize the language in this bill. The AMA will then work to find champions in Congress willing to introduce this legislation shortly after the new Congress is seated in November. There is much work to be done, and it is time for physicians to take the lead.