Munson's Bariatric Surgery Program - Munson Healthcare

Munson’s Bariatric Surgery Program:
Excellent Outcomes, Few Complications
MunsonHealthcare.org
A2 Reason to Celebrate
Physicians and patients from outlying
areas are seeing long-term success
A3 Going Full Tilt
Patient gets second chance to
‘live life right’; asks physicians to
keep an open mind
A4 Who’s It For?
Primary care physicians play key role
in identifying, following up with
surgical patients
A5 The Diabetes Connection
Bariatric surgery is having a significant
impact on type 2 diabetes and other
life-threatening diseases
A6 National Recognition
Munson named a Bariatric Surgery
Center of Excellence by exceeding
national standards
A7 Meet the Surgeons
The procedures and the surgeons
who perform them

Canadian Perspective: ‘Not One Patient
Says They Wouldn’t Do It Again’
Three years ago, Linda Benedek, a family physician by
training and a former Air Force flight surgeon, decided to
focus her practice exclusively on weight management and
the co-morbidities of obesity.
Her own struggle with weight led her to seek additional medical
training to become a diplomate of the American Board of
Bariatric Medicine (ABBM).
After becoming credentialed, she opened Celebration Medical
Weight Management in Sault Ste. Marie, Ontario, and offers
a six-month weight management program that, for some
patients, dovetails with the Bariatric Surgery Program offered
at Munson Medical Center. In the past 18 months, Benedek
has referred 25 of her 300 patients to bariatric surgeons at
Grand Traverse Surgery, PC.
Her program uses a three-pronged approach to tackling
obesity: behavior modification, diet, and exercise, with the
goal of achieving a 5 - 10 percent weight loss within six
months. She is her own walking testimonial, having lost 40
pounds and kept it off for three years.
“I don’t refer anyone for bariatric surgery until they have
completed the program,” she said. “Some patients, despite best
behavior modification and diet changes, are unable to lose
weight. We will look at bariatric surgery as an option, but the
intent of my program is not just to prepare people for surgery.
Mental and emotional issues with respect to food need to be
properly addressed, as the surgery does not eliminate those.”
Benedek makes it clear to patients that bariatric procedures
are only for “rule followers.” She screens out patients unlikely
to succeed because they are non-compliant in other areas –
such as treatment for diabetes. So far, that approach has
been highly successful.
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“I’m seeing excellent results. Typical weight loss is 100 pounds in the first year.”
Linda Benedek, MD, CCFP, FCFP
Diplomate of American Board of Bariatric Medicine
Celebration Medical Weight Management
Sault Ste. Marie, Ontario
“I’m seeing excellent results,” she said. “Typical weight
loss is 100 pounds in the first year. My patients have been
very compliant. I take a lot of time teaching them about
protein intake – it’s essential that they do what they’re
supposed to do.”
Benedek has observed improvement in all co-morbidities
in her post-op patients.
“Most of my patients are able to discontinue
their blood pressure, cholesterol, and diabetic
medications,” she said. “Even insulin is often
discontinued or markedly reduced.
The symptoms of osteoarthritis in their
knees and hips are significantly improved
with much less discomfort.
They’re all delighted – the ones with
complications and the ones without.
I have not had one patient say they
wouldn’t do it again.”
Support for Physicians and Patients
in Outlying Areas
Physicians and patients from outside of the Traverse City
area can expect a high level of service from the team at
Munson.
“I’m three hours from Traverse City,” Benedek said. “I’m
very pleased with the service I get from Traverse City.
They really do their best to minimize travel for my patients.
They’re very courteous, flexible, and amenable.”
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Benedek’s Program: Behavior Modification | Diet | Exercise > 5 - 10% Weight Loss in Six Months

Bariatric Surgery Gives Patient
‘A Second Opportunity to Live Life Right’
“I feel fantastic. The other day a co-worker
said, ‘Oh, you’re sitting in a chair with sides –
I’ve never seen you do that.’ I’ve discovered
I actually have a tailbone – I can feel it.”
Lesley Sawchyn, Sault Ste. Marie, Ontario
Lesley Sawchyn was a chubby child ballerina who grew into
a chunky teen basketball player. Despite being physically
active, by the time Lesley was a 37-year-old mother, she
weighed 330 pounds.
She has a plea for primary care physicians: “Be open minded
and open hearted. If you are a thin physician and you’ve
never been overweight, you do not truly understand what
it is like to be obese and how cruel society is to people who
are. Really try to understand where your patient is coming
from.”
Secondly: “Be fully supportive, but put the onus back on the
patient. There is no going back after making the decision for
surgery. You basically have one chance – the patient has to
be responsible for their own success.”
Lesley, a sign language interpreter for the Canadian
Hearing Society, completed a six-month weight management
program in Sault Ste. Marie, Ontario. She lost 32
pounds. When she gained it all back, she had a heart-toheart
with her physician, Linda Benedek, MD, in November
2008. “Nothing, nothing, nothing was working for me,”
she said. “I decided I’m too vibrant to be weighed down
by this weight.”
Lesley had a Roux-en-Y procedure
at Munson Medical Center
in March 2009, weighing 321
pounds. Ten months post-op,
she weighed 193 pounds.
Lesley had no co-morbidities.
While complication rates for
bariatric surgery at Munson
Medical Center are well
Roux-en-Y Procedure
MunsonHealthcare.org
Lesley before
(above) and
after (right)
below national averages,
they can happen. The wellestablished
collaboration
between her primary care
physician and her surgeon
became paramount when
Lesley developed an ulcer
and a stricture. Benedek
referred her back to
Munson Medical Center
for immediate care.
Despite complications, Lesley says she is extremely
pleased with her results, grateful to her local primary care
physician, and she’s highly complimentary of the team at
Grand Traverse Surgery. Lesley helps lead a lively bariatric
support group in Sault Ste. Marie, encouraging others to
adhere to the life-long dietary and exercise requirements.
“I’d do it again in a heartbeat,” Lesley said. “I was always
an active person, but now I can go full tilt. I’m in such
good hands. I’ve been given a gift – a second opportunity
to live again and do it right. Once you have the surgery,
you have an obligation to take care of yourself.”
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continued from A2
Patients are seen for an initial consultation, again for one
pre-op visit that covers everything in a half-day appointment,
and then they return for surgery. Patients who live
more than three hours away are asked to stay in Traverse
City until seven days post-op, when their drain is removed
and they are sent home. Patients are usually hospitalized
for three days, depending on their procedure. Follow-up
care begins immediately with the primary care physician.
“Surgery notes are transcribed and faxed immediately,”
Benedek said. “I have them in hand well before I see my
patient – I’m really kept in the loop. It’s a very smooth
process for my patients.”
“The back up support is excellent – one of the four surgeons
is always on call. If my patient runs into a problem
at midnight, a surgeon is available for telephone advice.
We have had some complications, such as a post-op leak
and a bowel obstruction, both of which required surgery
and those were promptly dealt with.”
Four Tips for Primary Care Physicians
Based on her experience, Benedek offers
the following advice:
Evaluate all behavioral aspects before considering
bariatric surgery – if those issues aren’t dealt with first,
the surgery is less likely to be successful.
Develop a rapport with a Bariatric Surgery Center so
you are familiar with the process and the required
follow-up for patients.
Don’t consider surgery for anyone who can’t quit
smoking. Patients must be non-smokers for at least
two months before a referral should be considered.
Make sure patients fully understand life-long nutrition
and lifestyle requirements after surgery. Rule followers do
well – the non-compliant patient is not going to do well.
A Guide for Primary Physicians
As the first providers who can help improve or save a patient’s life
through bariatric care, primary care physicians are the gatekeepers
for the Munson Medical Center (MMC) Bariatric Surgery Program.
MMC has taken definitive steps to provide the best opportunity for
patient success. The following criteria and steps can help physicians
determine if patients are eligible, and what to expect.
Bariatric Surgery Criteria
MMC bariatric surgeons follow the National Institute of Health
(NIH) guidelines for weight-loss surgery candidates to include one
of the following:
• Body mass index (BMI) of 40 or greater (100 pounds or more
above normal weight)
• BMI of 35 to 40 (50 to 100 pounds above normal weight)
with two or more co-morbidities
• Patient age: 18 - 65 years
• Patient record of unsuccessful attempts to lose weight in
a medically-supervised program
• Patient obesity-associated co-morbidities under medical care
Educational Seminar
Patients who meet criteria must attend a two-hour educational
seminar. “The seminar is offered once a month and is an important
opportunity to teach patients about the lifelong commitment to
proper nutrition, exercise, smoking cessation, and other behavioral
modifications,” said Mary Kay Williams, MSN, FNP-C, Coordinator
of the Munson Bariatric Surgery Program.
Next Steps
Once a patient makes the commitment, has the recommendation of
their primary physician, and the support of their family, they enter
the Bariatric Surgery Program. The next steps are consultation,
psychological evaluation, preoperative classes, and the surgery.
Long-term Care Management
Comprehensive care is a critical component of MMC’s Bariatric
Surgery Program. By focusing on medical management, nutrition,
exercise, nursing care, and psychological needs of each patient, the
support staff offers patients the optimum opportunity to succeed.
Post-op follow-up care occurs at one week, three weeks, six weeks,
three months, six months, nine months, 12 months, 18 months, 24
months, then yearly thereafter. A lifelong connection to patients has
proven to be essential to success.
Support groups also offer information and encouragement to
patients after surgery. “Meeting with other patients who have undergone
the surgery is vital to our patients’ success,” said Williams.
“They share in each others’ struggles and victories, and that brings
them comfort and strength.”

Bariatric Surgery:
A Cure for Diabetes?
Mounting evidence suggests bariatric surgery may be among
the most effective treatments for conditions including type
2 diabetes, hypertension, high cholesterol, non-alcoholic
fatty liver disease, and obstructive sleep apnea, according to
the American Society for Metabolic and Bariatric Surgery
(ASMBS).
“Surgery for severe obesity goes way beyond weight loss,”
said Kelvin Higa, MD, President of ASMBS. “This surgery
results in the complete remission or significant improvement
of type 2 diabetes and other life-threatening diseases in most
patients.”
Surgeons at Grand Traverse Surgery, PC, who participate in
Munson Medical Center’s (MMC) Bariatric Surgery Program,
are optimistic about use of gastrointestinal surgery as a treatment
for diabetes.
“We are seeing evidence that bariatric
surgery results in type 2 diabetes remission.
A high percentage of our patients have
normalization of their hemoglobin AIC
within two months of gastric bypass.”
Michael Nizzi, DO, Medical Director
MMC Bariatric Surgery Program
“Gastric bypass and other malabsorption procedures
(intestinal bypass) will become the procedure of choice for
type 2 diabetes mellitus remission,” Nizzi said. “This is still
investigational, but consensus is growing to decrease the BMI
threshold of which patients are candidates for surgery.”
New research indicates metabolic surgery may improve
insulin resistance and secretion by mechanisms independent
of weight loss – most likely involving changes in gastro
intestinal hormones. Many patients with type 2 diabetes
experience complete remission within days of surgery,
long before significant weight comes off. This has led to new
thinking that surgery may be appropriate for diabetic patients
who are of normal weight or only slightly overweight.
MunsonHealthcare.org
In the American Diabetes Association’s (ADA) 2009
Standards of Care Clinical Guidelines, the ADA bolstered
its section on bariatric surgery and its effect on type 2
diabetes and said “bariatric surgery should be considered
for adults with BMI greater than 35 and type 2 diabetes.
ASMBS and many other national medical organizations
also support using bariatric and metabolic surgery in type 2
diabetes patients with BMIs of less than 35 under a research
protocol.”
An article in the January 2008 issue of the Journal of the
American Medical Association (JAMA), written by
David Cummings, MD, and David Flum, MD, MPH,
both from the University of Washington in Seattle, reported
on a two-year randomized controlled trial involving type 2
diabetes patients with a BMI of 30 to 40:
• “Complete remission of diabetes at two years was achieved
in 73 percent of the patients in the laparoscopic adjustable
gastric banding group versus only 13 percent in the
medical/behavioral therapy group. The surgical group
experienced larger reductions in blood glucose levels,
glycated hemoglobin levels, estimated insulin resistance,
use of diabetes medication, and several features of the
metabolic syndrome.”
• “Among the 84 percent of patients with diabetes whose
disease remits entirely after Roux-en-Y gastric bypass,
one-third have blood glucose levels within reference range
without use of anti-diabetes medications before discharge
from their surgical hospitalization, at an average of less
than three post-operative days.”
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Munson Bariatric Program
Nationally Recognized
for Excellent Outcomes
The Agency for Healthcare Research and Quality
reports that the number of bariatric surgeries
increased 400 percent from 1998 to 2004.
More than 1,500 bariatric surgeries have been
performed at Munson Medical Center (MMC)
since the program began in 2003. Munson
and surgeons from Grand Traverse Surgery,
PC, were named a Bariatric Surgery Center of
Excellence based on demonstrated short- and
long-term outcomes and advanced treatment that
exceeds national standards for bariatric surgical care.
In addition, MMC was designated a Blue Distinction
Center for Bariatric Surgery by Blue Cross Blue Shield of
Michigan and is an approved provider for the Ontario
Health Insurance Plan (OHIP) for Canadian patients.
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Total surgeries by type | 2009
RNY Open 10
RNY Lap 193
Lap-Band 172
Lap Sleeve 36
Open Sleeve 1
Revisions 1
About 400 bariatric procedures are performed annually at
MMC. Bariatric surgery is successful if the patient achieves
a 50 percent loss of excess body weight within 18 months
following surgery. With comprehensive support provided
by Munson’s bariatric team, patients consistently exceed
that average – most reach a 75 percent excess weight loss
within 12 to 18 months post-surgery.
“Munson’s weight loss program includes experienced
surgeons who perform an average of eight bariatric procedures
each week,” said Roche J. Featherstone, MD, bariatric
surgeon. “We practice extensive patient screening, education,
and follow-up, which leads to our patients’ success, as well as
our recognized success as a team.”
Low Complication Rates
Nationally, bariatric surgery complication rates declined
21 percent between 2002 and 2006. Complication rates at
Munson Medical Center were 2.51 percent in 2008, well
below national rates. “With the exception of gastric banding,
all other primary and revisional bariatric procedures are
performed by two surgeons, rather than being assisted by
a physician extender or surgical assistant,” said Michael A.
Nizzi, DO, Medical Director of Munson’s Bariatric Surgery
Program. “The clinical pathway at Munson ensures that all
patients receive equal evidence-based therapies that limit
omissions in the care plan that could possibly lead to
sub-optimal results.”
Additionally, “laparoscopic procedures now account
for more than 90 percent of our cases,” Nizzi said.
“Physicians considering making a referral for bariatric
surgery at Munson Medical Center should feel very
confident that their patient will be safe and successful
because we have established a program that is achieving
or exceeding all national benchmarks.”

Lap Band ®
The LAP-BAND ® System
This minimally-invasive adjustable
gastric banding procedure
is the only reversible, FDAapproved
surgical obesity treatment.
A silicone band is placed around the upper part of
the stomach to create a new, smaller stomach pouch. The
band also narrows the stomach outlet, limiting the flow of
food. It reduces appetite and slows digestion. LAP-BAND®
is appropriate for patients who have a lower BMI and
limited co-morbidities.
Although current procedures yield above-average success
for MMC patients, the bariatric team looks to advancements
that include genetic therapy, gastric pacemaker,
and intragastric balloons, all of which provide options
to widen the bariatric care MMC provides.
Roux-en-Y
Surgeons perform this laparoscopic
procedure through tiny incisions,
during which the stomach is made
into a small pouch that restricts
food intake. The duodenum and
first portion of the jejunum are
bypassed, thereby reducing calorie
Roux-en-Y
and nutrient absorption, so careful
attention is placed on patient education and dietary
evaluation post-surgery.
Vertical Sleeve Gastrectomy
Vertical sleeve gastrectomy surgery
involves only the stomach, and
consists of reshaping it from a
pouch into a long narrow tube
and removing two-thirds of the
stomach. The narrower stomach
restricts food intake by allowing
Vertical Sleeve
only a small amount of food at
one time. New connections are not made between the
stomach and small intestine, and there is no re-routing
of the intestine, or reduced absorption of nutrients.
Meet the Bariatric Surgeons
Total Surgeries Performed at Munson Medical Center
Roche Featherstone, MD
RNY Open RNY Lap Lap-Band VSG
111 211 130 23
Medical School:
Wayne State University School of Medicine, Detroit, Mich.
Residency: St. John Hospital, Detroit, Mich.
Joined MMC Staff: 1996
David Kam, MD
RNY Open RNY Lap Lap-Band VSG
2 74 82 8
Medical School:
Wayne State University School of Medicine, Detroit, Mich.
Residency:
Butterworth Hospital, Spectrum Health, Grand Rapids, Mich.
Fellowship: University of Pittsburgh, Pittsburgh, Pa.
Joined MMC Staff: 2008
Michael Nizzi, DO
RNY Open RNY Lap Lap-Band VSG
95 253 148 29
Medical School: DesMoines University Osteopathic Medical
Center, Des Moines, Iowa
Residency: Michigan State University College of Osteopathic
Medicine, East Lansing, Mich.
Joined MMC Staff: 1999
Steven Slikkers, MD
RNY Open RNY Lap Lap-Band VSG
27 203 191 19
Medical School:
Loma Linda School of Medicine, Loma Linda, Calif.
Residency: Mayo Graduate School of Medicine, Rochester, Minn.
Joined MMC Staff: 2004
Referrals and Consults
To refer patients for a consultation or specialized care,
or for a surgical consult, please call (231) 935-8900.
For 24/7 hospital transfers, please call 1-800-468-6766.
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