LAPAROSCOPIC GASTRIC BYPASS TUFTS NEW ENGLAND MEDICAL CENTER BOSTON, MASSACHUSETTS 12/06/06 00:00:10 ANNOUNCER: Live from Tufts New England Medical Center in Boston, Massachusetts, a surgery that goes a long way towards helping people suffering from obesity regain their lives: laparoscopic gastric-bypass surgery. Dr. Scott Shikora, chief of bariatric surgery at Tufts New England Medical Center and surgical director of the Medical Center’s comprehensive obesity consultation center, along with bariatric surgeons Dr. Julie Kim and Dr. Michael Tarnoff will perform the surgery. 00:00:38 RICK PACHECO: I still enjoy food, absolutely, but we enjoy it in a different way. 00:00:43 ANNOUNCER: You will also hear from an extraordinary couple who, between them, lost 500 pounds. You’ll learn why they chose the obesity consultation center and how it changed their lives. 00:00:53 SCOTT SHIKORA, MD: The treatment plan doesn’t end with the operation. 00:00:56 ANNOUNCER: Dr. Shikora says patients must understand the operation is only the first step of many. 00:01:01 SCOTT SHIKORA, MD: And it’s vitally important after these procedures that the patient follow up permanently with the program where they had their surgery. 00:01:08 ANNOUNCER: You may e-mail questions at any time during the program by clicking the MDirectAccess button on your screen. You can also make an appointment or make a referral. Now we go live to Tufts New England Medical Center and the moderator of today’s program. 00:01:25 MICHAEL TARNOFF, MD: Good evening, everyone., and welcome to Tufts New England Medical Center. We’re based in Boston, Massachusetts. This evening, through the innovation of lots of several different types of technologies, you’re going to have the privilege of witnessing and watching a live, minimally invasive weightloss surgery aimed at helping patients lose weight and maintain that weight loss. The most important aspect of tonight’s program is your ability not only to watch us but to interact and ask us questions, and you can do that by pressing the MDirectAccess button, which I believe is at the top of your screen. I’m Dr. Michael Tarnoff. I’m a general and bariatric surgeon here at Tufts New England Medical Center in Boston, and just behind me, my two partners, Dr. Scott Shikora and Dr. Julie Kim, are getting ready to perform a laparoscopic gastric-bypass procedure, which you’ll be able to witness. Dr. Shikora is the chief of bariatric surgery here at the institution and will be talking to us in a moment about the patient and about what they’re going to be doing. Also, Dr. Julie Kim, also one of my partners, is a bariatric attending

surgeon here and will performing the procedure along with Dr. Shikora, and I’ll be here to moderate and help illustrate what we’re going to be doing and answer your questions, and we’ll just have a discussion amongst all of us about what’s going on. So with that, let me introduce Dr. Shikora and ask him to tell us a little bit about this patient and how she got here. 00:02:50 SCOTT SHIKORA, MD: Thank you very much, Mike. Good evening, and good afternoon for those on the coast. Thank you for joining us. This is a young lady who’s 33 years of age and has a body-mass index of 46, which means that she’s more than 100 pounds over what would be her desired body weight. She has a fatty liver which at this point doesn’t cause her problems but in the future can even lead to cirrhosis of the liver. She also has very, very bad heartburn and reflux symptoms as well as shortness of breath when she walks. She has been in our program here several months, has been appropriately prepared for surgery, educated, selected, and after all treatment options were discussed with her, she elected to have this procedure. 00:03:38 MICHAEL TARNOFF, MD: Okay, and Dr. Kim? Julie Kim is next to Scott. Can you just tell us a little bit about where you are in the procedure at this stage? 00:03:47 JULIE KIM, MD: Right now, we’re in the very beginning of the operation. We’ve basically put our ports in, which act as channels for our instruments to go through, and I’m just about to put right now, the very last trocar. 00:04:00 MICHAEL TARNOFF, MD: So what you’re seeing there are little plastic tubes. You can see the patient’s abdomen in the center of your screen, and there are plastic tubes that are placed into the patient’s abdomen. She’s obviously asleep. Her head is to the left of your screen and her feet are to the right, and these tubes give us access into her abdomen. It’s about 6:30 in the evening here on the east coast, and so many of you, if you weren’t watching this, might be watching Wheel of Fortune, and we actually have nurse Vanna, Dana Woodford here, who’s going to come in. Here she is. This is a whole team approach, and we’ll be introducing all the members of our team here momentarily, but I just want to illustrate for you what a gastric bypass actually is before they start so that you’ll have some basic understanding of what we’re doing. If you look at this chart, this shows you what normal anatomy looks like. This is the esophagus, which connects the mouth down to the stomach, which is depicted here, and that drains into the small intestines, and then that drains into the large intestines and then out. This is the liver, and then over here not depicted is the spleen. If we can move over to the other picture, we’ll show you what happens with gastric bypass, and there are sort of three major steps, although there’s many more than that that you’ll see this evening. The first step is to divide the stomach into a small pouch, and that’s done with a stapler, which is why this is sometimes referred to as “stomach stapling,” and you’re going to see that in a moment. But you can see here a very small pouch of stomach, and the rest of it is excluded or divided. We then go down and divide the small intestine. If you remember, this was intact. We bring a limb of small intestine up and secure it to the new pouch so that the food that you eat comes into the small pouch, which helps the patient eat less. It won’t do it for them, but it’ll help them, and we’ll talk more about that in a few minutes. The food then comes down, and this second, lower connection that’s made, which you’ll also see, allows for drainage of bile that comes from the liver and stomach acid that comes from the stomach. That all mixes here, and then digestion proceeds as normal. So those are the three broad steps that you’re going to see this evening, and are you ready to – 00:06:03

SCOTT SHIKORA, MD: We’re ready. 00:06:05 MICHAEL TARNOFF, MD: Okay, so they’re going to begin, and I’ll assume at this point that they have a view of the inside of the patient’s abdomen. And the instrument that you see there is a stapling device, which you can see now being deployed. That’s actually cutting tissue, and then it lays down rows of staples on either side. So you can now see -- much like you would do if you stapled paper together, you can actually see that that instrument has cut the stomach and then has resolved it in staple lines, and maybe, Scott or Julie, you can just show us what those staple lines look like. 00:06:39 SCOTT SHIKORA, MD: Well, first of all, this is the pancreas that we’re seeing very clearly below the stomach. This is the stomach. The staple lines are over here. We did the first cut. We’ll probably do five or six to complete the separation of the stomach. 00:06:53 MICHAEL TARNOFF, MD: So this refers back to that first step, and the tissue to the left of that instrument is going to be the new stomach, and the tissue to the right is the old stomach, which will stay in place. You can see, in the upper-right-hand corner of the screen, a purple organ. That’s the spleen, and then above, that pinkishcolored organ is actually the liver. 00:07:14 SCOTT SHIKORA, MD: Which -- we’ve retracted the liver off of the stomach to give us the work space, and we did that before we went live. Can I get the stapler? Thank you. 00:07:22 MICHAEL TARNOFF, MD: Scott, let me ask you – while you guys are working, do you want to comment on, maybe, what this patient went through in brief just to get to this point? 00:07:30 SCOTT SHIKORA, MD: Well, after entering our program, she met with one of our behavioral therapists twice, during which time she was not only evaluated, but she was behaviorally prepared. She made some of the lifestyle changes that she’ll need to make to succeed. She also participated in a 6-week behavioral-change program, which is set up to create better lifestyle habits, better eating habits, importantly the benefit of good nutrition, exercise, and stopping smoking, et cetera. She met with a dietitian at least once – can I have the long grasper? – to assess what her diet was like beforehand so that she would recognize some of the issues she had around her eating, and then afterwards – for the diet afterwards to understand what the new diet would be like and the importance of vitamins and protein. She met the exercise physiologist, who helped her establish a program for activity, and that’s individualized by each patient based on their ability to exercise or not. And then she met with me, and I spend an hour with her going over this operation in detail. I made it very clear to her that while the operation is highly successful, there’s risk involved, and then after that, she agreed to go forward. 00:09:00 MICHAEL TARNOFF, MD: SO that’s a good transition. The decision to undergo weight-loss surgery is never a simple one, and there’s lots that goes into it, and we’ll talk about some of the more specific, absolute indications in a moment. But we asked one of patients who’s actually gone through this process to give some comments and give you some perspective on his thought process in terms why he chose to undergo gastric bypass surgery, and I think you’re going to see that clip right now.

00:09:25 SCOTT SHIKORA, MD: We just finished the pouch. So it’s completely separated from the rest of the stomach. Okay. 00:09:35 RICK PACHECO: I had head lots of horror stories. Some of them hit fairly close to home with people that I was acquaintances with that has lost loved ones throughout a surgery process. And – however, it took Julie really doing some research and coming up with facts and saying to me, “Okay, Rick, you have a less of half a percent chance of dying on the table compared to a 50% chance of dying within the next five to ten years because of your obesity complications that you’ll have,” to make me wake up and say, “I need to do this.” And I will say that after my first appointment at – here at New England Medical Center -- my first appointment when they finally told me how much I did weigh – because when you weigh that much, you don’t know. There’s no scale that goes that high. So after my first appointment, I’d asked the psychologist who I met with what I weighed, and I nearly broke down in tears. And at that moment, I dedicated myself to saying, “I will succeed at this.” The doctor said, “You need to lose 50 pounds prior to surgery. I said, “I will lose 50 pounds before my next appointment with you,” which was six weeks later, and six weeks and one day later, I had lost 50 pounds. So my determination happened immediately, and I never looked back. 00:10:58 MICHAEL TARNOFF, MD: So that’s one story of many that we hear in the course of our practice here at the medical center. Patients go through a pretty rigorous process once they express interest in coming here, and Dr. Shikora gave you some of the highlights of that. And that’s one personal story, but there are many like that that we hear on a daily basis, and there are numerous reasons that patients consider doing this. If we turn our attention back into the procedure here, they have actually finished creating the pouch, which is what they’re holding open. So that small, little stomach now connects back to the esophagus, and they’re putting a device in that is going to assist in our ability to connect a small – piece of small intestine up to the pouch. So there’s the new stomach, and they’re placing what we call an anvil. And if you think about the way a stapler will work – just think of a desktop stapler. There’s a section that fires a stapler, and there’s a piece of metal that it fires into, and that’s what that instrument that they just put in is. And this will make more sense to you as we get near the end of the procedure, but for now, this is a device that’s going to help us reattach the little pouch down to a segment of intestine, which will basically allow for the patient to eat and then have passage of nutrients down the normal route. What you’re seeing is live, so we’re not able to edit any of this. So this is realtime, and you can sort of get a sense of what each of these steps involves. Obviously, the patient’s asleep, and probably the last thing she remembers is meeting our anesthesiologist out in the holding area and being given some medication to keep her comfortable and get her ready for this. So she’s obviously in no distress and is being monitored by our team here of anesthesiologists, and maybe as you’re working, Julie, Dr. Kim, you could comment a bit about the team approach that we have here and that many around the country have employed in terms of weight-loss surgery and what goes into that. 00:13:00 JULIE KIM, MD: [ inaudible ] approach to weight-loss surgery is pretty much considered standard of care today, and that’s because the operation isn’t just about the surgery. It’s about all the challenges that they’re going to face for the rest of their lives. So we have a multi-disciplinary treatment, which includes behavioral providers. We at Tufts have three psychologists here. We also have a full spectrum

of two dietitians, as well as three internists that evaluate the patients and get them ready for surgery. 00:13:40 MICHAEL TARNOFF, MD: So what you’re seeing there is – they left a small bit of the pouch open so they could get that anvil or stapling device in, and now they’re going through again with the stapling device. And they are basically closing that segment off. So what you’re going to be looking at here in a moment is – and maybe we can show them with graspers. That’s the size of the new stomach. That’s basically as big as its going to be. We typically refer to it as being the size of a thumb, and I think the most important thing to understand as you watch this and learn about weightloss surgery, be it gastric-bypass surgery or any other forms, is even with a stomach that’s now that small – and maybe, Julie, you can show the pouch versus the old stomach. So that’s how small it is. Go ahead. 00:14:32 JULIE KIM, MD: Normally, a person’s stomach’s about size of a football, and now this is about the size of a thumb or a hard-boiled egg. 00:14:38 MICHAEL TARNOFF, MD: Maybe just pick up – once you finish cutting that, just pick up the old stomach and we can show them the size discrepancy. So that’s – people refer to their stomach as their whole abdomen, but that’s really the organ. That’s your stomach. That’s where your food goes that functions as a reservoir and as a secreter of acid and other digestive enzymes. That stays in place. We don’t remove that. You can sort of get a first-hand view that if we were going to go remove that, we would have to do several more steps to detach that organ. So that will actually stay in place. It’s not taken out. The tissue’s left alone. And at this point, if you think about anatomy, we have the mouth leading down to the esophagus, leading into that little pouch with the anvil, or that device, sticking out of the end of the pouch, and we’re going to come back to that in about 20 minutes or so to re-establish the continuity of this patient’s GI tract. If we left her as she was right now, she’d lose a lot of weight, but it would be all for the wrong reason. Everything she ate would just come right back up. So now they’re going to lift up the stomach, which you can see there. 00:15:42 SCOTT SHIKORA, MD: Also note, she has a very large, fatty liver. This liver’s much larger than most. 00:15:49 MICHAEL TARNOFF, MD: And fatty-livered people talk about or understand that morbid obesity – once your body-mass index goes – once your body weight goes about 100 pounds above your ideal body weight or your BMI or your body-mass index goes above 35, there’s a high association of other health problems, things that we call “co-morbid conditions.” And that actually begins when your body-mass index exceeds 27, and if anyone wants to calculate a BMI, they can go either on our website, obesityconsult.org, or, really, anywhere on the internet to find a BMI calculator, and you can actually calculate your own BMI by entering your height and weight and just getting a sense of where you fit in. Weight-loss surgery, because of the drastic step that it is and because of the complexity associated with the procedure and the life changes that go with it, is only indicated for patients hose body-mass index exceeds 35 if they have other health problems or 40 independent of that. And that’s part of what we go over with you when you first call for an appointment of want to be evaluated for this kind of procedure. For those whose body-mass index is less than that, we do have a medical weight-loss program here that is also comprehensive and helps patients in any number of ways, whether it’s self dieting or very-low-calorie diets or medications, and the decision of whether

surgery is appropriate is obviously one that’s made with the patient and is very much individualized. Assuming now that we still have the image inside. What you’re seeing – they’re lifting up this yellow tissue, and what this yellow tissue is is really just fat tissue that we all have. And so the heavier you are, the more body fat you have both peripherally out in your legs and your arms and in your abdomen. Men tend to have most of their weight in their abdomen. So they will have more of this yellow tissue, relatively, than a woman will, even at the same body weight. They are now lifting an area that’s known as the mesocolon, or the actual blood supply to another organ, which is known as the transverse colon, which is part of the large intestine. And they’re making a window in that space so that we can bring up the small intestine and reconnect it to the little pouch. And again, as the steps go on, some of this will begin to make more sense, and maybe if I can get nurse Vanna back – is she still here? There’s Dana. Let’s go back to our diagram. I guess we can start to introduce our team. This is Dana Woodford, who works with us here at New England Medical Center. She’s one of our very talented OR nurses, and there’s a whole team that goes into doing this. You can see behind me the number of people that are here. These are all representatives either of nurses or of anesthesia or of industry. They are companies that make all of the equipment that you see, and we’ll introduce everybody in a few minutes, but all of these folks have taken time to come be with us here tonight and most of – spend most of their time either in our OR or in other Ors around the country making sure that their technologies work appropriately and the way that they are indicated for. So let’s go back and look at our diagram. This is the transverse colon, and there’s blood supply to that in the form of what’s called mesentery. And so what they’re doing is making a little opening through that. The mesentery isn’t depicted here, but they’re making a little opening so that this loop of bowel can pass through the opening. And that’s going to allow us to bring the bowel back up to the little pouch and get it connected. So that’s the step they’re at. Where they’re headed is to actually go back down to the small intestine and divide, and I believe we’re going to see that here. They’re ready. Let’s go back inside the abdomen, and we will get a look again at another stapling device. 00:19:49 SCOTT SHIKORA, MD: We’ve reflected that fatty tissue forward so we could see where the bowels are. 00:19:54 MICHAEL TARNOFF, MD: Right. So what you’re looking at now is small bowel and small intestine. So this is just immediately below the stomach. People have about eight to ten feet of small intestine, and that helps with nutrient absorption and what not. The stapling device is being deployed now to cut the tissue. You can see the bowel is getting cut, and its blood supply, or its mesentery, which is the yellow fat that you can see, is also getting divided. One of the things you’ll notice is that there’s very little bleeding, although there’s some there at the corner now, and they’re going to use another instrument to come in – this is an instrument known as the autosonics, which is actually a device that very rapidly vibrates and creates heat, and that allows us to seal or coagulate the blood vessel, and you can see with a very quick maneuver of that device, we were able to stop any kind of bleeding. What you see now is a rubber drain that was placed in the abdomen when we weren’t looking, and that is going to be connected to the segment of intestine which Dr. Shikora is holding there in his left hand. Maybe you could wiggle that piece of – there you go. That piece of intestine is going to get connected to this rubber tubing, which is then going to get brought up ;behind the large intestine through that tunnel they made, and that’s going to get connected to the small intestine. So this is sort of the rerouting of the intestines that goes along with gastric-bypass surgery. I think we have some e-mail questions, and question number one here: “What happens to the

rest of the stomach?” So that’s a very common question, and you can sort of see first-hand here what we do with it and why we do it. But if you look in the upper-lefthand part of the screen, that’s the rest of the stomach, what’s known as the excluded stomach now. That organ – the stomach in general functions to act as a reservoir for the food that we eat. That’s first and foremost. It also acts as an organ that begins the process of digestion. So it’ll begin to mix the food that we eat, and then it’ll, in a regulated fashion, release those food particles into the intestine that Dr. Shikora is now holding. So it loses its reservoir function because that’s now where the pouch comes in, that small stomach, the new stomach, but all the other functions maintain themselves. So the ability of the stomach to make gastric acid, which then flows down the intestine and will flow through the connection we’re making to mix with the food that we eat and aid in the digestive process. That’s still an important function. It also has other digestive functions that it will maintain that’ll help you absorb Vitamin B12 and some other nutrients, and that’s why we leave it in place. On a very, very rare occasion, we might remove it, but I would say well over 99% of patients will keep their excluded stomach, and it will maintain its function. Another question: “Does the patient have diabetes or any other severe co-morbidity? Scott – 00:23:00 SCOTT SHIKORA, MD: She doesn’t now, but she’s a young woman, and there’s a high likelihood that within the next decade or two, she will. 00:23:09 MICHAEL TARNOFF, MD: And that goes along with obesity, and we certainly know now from scientific study, which is something we didn’t have a few years ago, that untreated morbid obesity, because of the development of diseases like Type II diabetes, like high blood pressure, like sleep apnea, carries with it a higher rate of death than any of the risks associated with elective gastric-bypass surgery, and that’s not something that the media has done a very good job publicizing. The procedures do have risks, and we will go over that before we conclude tonight, but the risk of an elective operation, when done in an experienced center like ours, are less than any of the risks associated with untreated morbid obesity, and that’s carrying through the assumption that patients can lose weight transiently but not lose weight in the long term and have any form of durable weight loss without an intervention like this. What you see them doing now – not to get too far behind – is they’ve aligned the two segments of small intestine. The one on the right actually connects back – Julie, just before you do this, can you just point to the stomach? Maybe just outline very briefly the route from the stomach down to the bowel that Scott’s holding. If you can just – just in a very cursory way just do that, just with a loop, maybe. 00:24:28 JULIE KIM, MD: The stomach is here, and basically, it goes down into the duodenum, and then it continues on and comes underneath the colon as the first part of the intestine right here, and that’s very – a connection just after the stomach. 00:24:42 MICHAEL TARNOFF, MD: SO that limb that you’re looking at right in the center of your screen is actually going to drain the old stomach, which makes acid, and it’s also going to drain the liver, which makes bile, and the pancreas, which makes enzymes. And all those digestive enzymes are vitally important to healthy nutrition, and we have to have a route for those to excess – to exit and then mix with the food that you eat And so what you’re seeing now is placement of the stapler to one limb that carries all the digestive enzymes, and the other limb, which is actually going to be brought up again through the drain behind the colon and brought up to the small pouch. So they’ve just brought the stapler in to both remnants of the bowel, and I

don’t know if you can hear or not, but they’ve just deployed the stapler, and as you can see there, it just cut the tissue and stapled the edges together. So we’ve now connected the drainage limb for the digestive enzymes with the drainage limb from the pouch. And this is a key step because it basically permits normal digestion in the remainder of the GI tract, and it’s an important thing to understand about gastricbypass surgery is that while it’s a highly effective, long-term weight loss solution, it does so while preserving good nutrition. And Scott has a strong background in clinical nutrition, and maybe you want to just make a couple comments, Dr. Shikora about nutritional – not so much complications of this ,but considerations and things that patients need to be aware of. 00:26:13 SCOTT SHIKORA, MD: Well, first and foremost, they must eat a high-protein diet because if they’re eating such small meals, they can end up with a protein deficiency, which would affect their immune system, healing, et cetera. They also much take vitamins because they won’t get enough vitamin in their diet from the small meals they’re eating, and also, they won’t absorb the vitamin as well. So what we do in our program is strongly recommend a high-protein diet, low-fat, sugar-free, and supplemental vitamins. And patients are required to follow up with us yearly so that we can measure their vitamin levels and check their overall nutrition. It’s okay to be like the Pachecos and lose 500 pounds between you, but if you’re malnourished, you’re going to do it and have poor health. 00:27:01 MICHAEL TARNOFF, MD: So they’re now closing off – these are just some technical steps in terms of getting this connection ready, and they’re now closing off the opening that they made with the ultrasonic device that gave them a route to get the stapler in, and they’re just finishing the step here to close this off. We’re going to cut to another clip, but just for a moment, I just want to ask Dr. Kim – we have a question here that wasn’t circled, but it is one that I want to answer. It says, “Why would a person do this and not just watch what they eat and work out? Our patients hear that all the time. 00:27:35 JULIE KIM, MD: Unfortunately, we don’t know exactly what causes obesity [ unknown ]. What we do know is that diets in many patients don’t work. Most people who come to our program have tried for many, many years, and they may in fact have even lost weight. The problem is that it’s very difficult to maintain that weight loss. 00:27:56 MICHAEL TARNOFF, MD: And that’s, you know, an important point. Most of these patients have lost 50, 100 pounds. It’s not uncommon to hear that. What these operations get at is not so much one’s ability to lose weight. It’s one ability to lose – one’s ability to lose weight and keep it off, which is really where the problems lie. We alluded a little earlier to the fact that this is such a personal; decision, and we want to give you a little more insight into some of what our – into some more of what our patients have thought with respect to that. So while we continue with the operation, let’s go hear what another patient has to say. 00:28:36 JULIANNA PACHECO: I thought I was going to have to give up all these foods that I loved so much that were my friend, and Rick and I would go out to dinner every single weekend. What are we going to do now? This totally changed our relationship. Where are we going to go? What are we going to do? Food was the center of our relationship, and we ate together all the time. 00:28:57

RICK PACHECO: And we actually had that conversation prior to surgery, which was, “What are we going to do after surgery? This is who we are. This is our – this is, you know, what we do together. We go out to eat. We enjoy eating.” 00:29:12 JULIANNA PACHECO: We get take-out together. 00:29:14 RICK PACHECO: We would, you know, be out -- Julie says every weekend, but it was a lot more than that when you include take-out, and it really was who we were. It was our personality, and it’s sad to think back now and realize that ‘s what it was. But prior to surgery, that was a big adjustment for us. “What are we going to do next?” And we actually sat down and made a list of all – these are things that we hopefully can do together, and some of those things we’ve been able to do, and some of those things we have planned for the future. And it’s such a different lifestyle now. Do we still go out to eat? Absolutely. Do we still enjoy food? Absolutely. But we enjoy it in a different way now, and we no longer use it as the center of our relationship. 00:30:02 MICHAEL TARNOFF, MD: So if you’re a prospective patient, or you’re someone out there thinking about weight-loss surgery, you may very well identify with some of what they’re saying, and I can only reiterate that they represent, really, one of many stories that we hear on a daily basis here. Obesity affects people in innumerable ways, and the more I’ve done this, the more I’ve begun to understand some of the prejudices that occur against the morbidly obese and some of the issues that they face, things as simple as walking on an airplane or sitting down in a normal-sized chair or even going to the bathroom. And when you begin to talk to individuals who are afflicted with this and understand that they’re trying to help themselves and that they’ve spent a lot of time and effort doing that, it really begins to underscore a little more of the help that they need, and that’s what centers like ours are really all about. We’ve had lots of questions come in. I do want to get to some of those. Let me just see where we are in the procedure. 00:31:02 SCOTT SHIKORA, MD: We’re finishing up the bowel connection, and we’re probably about five minutes away from connecting the bowel to the stomach itself. 00:31:10 MICHAEL TARNOFF, MD: Scott, while you’re doing that, one of the general questions that come up – you’re witnessing a gastric-bypass procedure, which is still the most common operation that we do here at New England Medical Center and that most centers across the country do. But we’ve had several questions come in through email about the role of other procedures, like the lap band. Do you want to make a general comment about lap band versus gastric bypass in terms of who might be appropriate for which and…? 00:31:37 SCOTT SHIKORA, MD: A lot of it is going to be patient decision when they meet with us, and we’ll discuss the operations at length, the pros and the cons, the risk, the benefits and then let the patient decide which one they believe, based on the conversations, based on their own learning, might be better for them. The lap band is a different operation. It has somewhat fewer complications, but it might not have as guaranteed a weight – as much weight loss, and it’s all individual and really based on patient lifestyle, preferences, et cetera. 00:32:13 MICHAEL TARNOFF, MD: And, Julie, while you’re working, how do you – how do you – consider – considering gastric band and other alternatives, do we happen to know if this patient considered that? Did we discuss that with her?

00:32:30 SCOTT SHIKORA, MD: I did, but I think, as I recall, she had done her homework and felt that this one was more conducive to her lifestyle. 00:32:41 MICHAEL TARNOFF, MD: So what they’re doing now is passing the small intestine up behind the colon, and that’s now the limb that’s going to get connected to the pouch. There it goes behind the stomach, and it’s brought up, and we’re going to spend the next few minutes here connecting the small intestine to the pouch, and again, that’s a vital step because that basically allows for a route for the food that this patient will eat to go from the pouch, down the intestine, and through the normal route of digestion. There are complications that go along with weight-loss surgery, and these have been well-publicized both in a positive light and in a negative one. And the discussion that I have and that I believe my partners have with every patient that we see first underscores the idea that you must really look at this from a risk/benefit perspective. If you’re a patient who has tried all other forms of weight loss and has either succeeded in the short term or even in the long term but can’t keep weight off and just feels like they’ve had no other – no other route, then that’s when you begin to consider weight-loss surgery, and again, your body-mass index needs to be at least 35, and you must demonstrate that you have tried and been unsuccessful at any other form of conventional weight loss, be it diet drugs or low-calorie diets or self-dieting plans. Once you make the decision to undergo weight-loss surgery, it really gets into, like I said, a risk/benefit assessment, and as I alluded to earlier, we now have scientific study to show us that if you’re a patient who falls into the category of one that will have untreated obesity so you spend time yo-yo dieting, constantly losing and gaining weight back and at tat, gaining more weight back, then your risk of mortality and your risk of an unhealthy lifestyle and an unsatisfactory life begins to outweigh any of the risks associated with these procedures. We put on the internet about a year ago a pretty comprehensive presentation about the risks associated with this operation, and I can certainly list them and illustrate some of them for you here, but if you want more information on that, you can go to resources like obesityhelp.com and look for our webcast that gives information on the risks associated with this procedure. Overall, the complication rate at our institution is in the 5 to 10% range, so about 90-plus percent patients come through, have the procedure that you’re seeing, spend about two days in the hospital and then go home, begin to lose a lot of weight, and really never look back. About 5 to 10% of patients will experience some form of complication. The four ones in particular that we see and that we spend most of our time treating when they occur can be described in brief, and maybe -- Julie, want to make a comment about the complication of leak and bowel obstruction, bleeding, and blood clot? Maybe just a sentence or two on each? 00:35:58 JULIE KIM, MD: Sure. In general, I think we’re fortunate that things like you mentioned are relatively low given the number of cases that we do. Our leak rate – and what a leak is is basically -- any of the staple lines hat you saw, if you have a tiny hole, can leak out gastrointestinal juices. And that’s something that can make patients very sick. We’re very fortunate. Our incidence of acute leaks is well under 1%, and I can’t even think of, in the last couple years, an acute leak that we’ve had. Bleeding is also something that can happen whether you inadvertently poke one of the organs, cause – or have a problem at one of the staple lines. Bleeding is something that we can – that we see, and fortunately, most of that bleeding resolves without any kind of intervention and falls into about the 2 to 4% range. 00:36:57 SCOTT SHIKORA, MD: Hold the liver over a little.

00:36:59 MICHAEL TARNOFF, MD: What they’re doing now is placing another stapler – this is a second type of stapling device – into the small bowel. This is the small bowel that was divided about 20 minutes ago. It was brought up behind the colon connected to that rubber drain. And now you begin to understand the relationship of this instrument to the one that was placed in the little pouch at the beginning of the procedure. The instrument on the right is being united with the instrument on the left, and what it will do is cut a 15-millimeter hole between the small pouch and the small intestine. So that’s the outlet by which food will pass into the intestine, and then it will staple, just like you saw the other device work, into the anvil, and that will secure the tissue. And what Dr. Kim just referred to, a leak is when one of the areas that was stapled opens. And this is only a risk for the first few days. It’s probably the most catastrophic thing that can happen after gastric-bypass surgery or any operation where we’re stapled tissue or where we’ve tissue, something known as an anastomosis. So this can happen if you have colon surgery. This can happen if you have small-bowel surgery for some other reason, but with the amount of gastricbypass surgery that’s been done in the last few years, this has gotten a fair amount of attention, and when the procedure’s done by surgeons skilled in the steps and in the use of the equipment, that complication tends to not occur much more than about 1%. So they’ve just fired the stapler, and they’ve united the small pouch with the small intestine, that they’re maneuvering now to get the stapler out. That’s now been done, and now they’re going to spend a few minutes here basically closing off that loop of small intestine that you see on the left side, and that’ll also require the use of another stapler. So you can sort of see sometimes where this operation is sometimes misnamed “stomach stapling.” It’s probably a common term that’s used, but it really sort of underscores – or underemphasizes the significance of what we’re doing. They’re moving rather quickly, and I don’t want to let time go by without introducing everybody here that works with us. It takes a real team approach to have this kind of surgery, not just from the standpoint of the surgeons but from the standpoint of all those around us, from the companies that make this equipment to all the support staff we have, and Dr. Shikora, if you’d like to do the honors of maybe introducing our team – 00:39:41 SCOTT SHIKORA, MD: I would. First, at the head of the table, is doctors Christina Ralph and Henrik Wyrm, who are our anesthesia team tonight. The anesthesia department here is superb. We work with many of the individuals, the doctors, the nurse anesthetists, and they’re all wonderful. We’ve really moved along well, and this has gone very, very well without any problems, and a lot of that is not because of Dr. Kim and I but because of Dana, who you’ve already mentioned, and Debbie Winter over here, who’s been handing us the instruments. They’re superb, and they can really make or break the operation. And they’re so professional in that the instruments are handed, everything’s working, everything’s appropriate. You don’t even have to ask for it anymore, and they do a great job. And I also would just like at the same time thank the other nurses and scrub techs that we work with on a daily basis because they’re half of our success. 00:40:40 MICHAEL TARNOFF, MD: Do you want to make the – a comment on the importance of two skilled surgeons? We certainly do a lot of teaching and training here and have emphasized to the surgical community that when a surgeon wants to get involved in this, they not only train themselves, but they train up someone to work with them. Well, as the newspapers have clearly pointed out – and as I think most in society recognize – these are very complex operations. These are high-risk patients, and the potential for devastating complications occur. One of the things that we’ve found

here has really helped us keep the complication rates down to a – I don’t want to say a minimum, but at least a tolerable number – is the fact that we don’t go into these cases unprepared as far as the experience level of those operating. This is the type of case where you can operate with an inexperienced resident, a junior resident, et cetera. And in our program here, it’s usually – it’s two attendings or an attending and our fellow and occasionally a very experienced chief resident. I think the important point to make for anyone out there considering this is that wherever you go, you want to get an assessment not only of the surgeon but of the hospital. We were just designated a center of excellence by the American Society of Bariatric Surgery, which is a designation that we’re certainly proud of and one that we think is going to be increasingly important as regulations come in as to who can perform weight loss surgery. And that applies way beyond surgeons in the operating room and really gets at the institution. And Tufts New England Medical Center has certainly thrown all of its resources behind the program that we have here both in terms of operating rooms that we work in, the support on the floor in terms of proper equipment to go along with the needs of morbidly obese patients, and that really even extends to attitudes. Morbidly obese patients very commonly feel ashamed or uncomfortable, and you need to be in an environment where you don’t feel that way particularly when you come into get help on this level. Well, we know that they’re actually nearing the end of the procedure here. Could you just give – maybe, Dr. Kim, give us a little bit of an overview of where we are. Show us the pouch and the intestine and just review some of the anatomy. 00:43:16 JULIE KIM, MD: Basically, this is the little stomach that we made that now is about the size of a thumb or a golf ball, and the food comes down through the esophagus and now enters the small intestine. And then the food mixes with the digestive juices down below in a connection that we had previously created. 00:43:44 MICHAEL TARNOFF, MD: So they’re going to go in now, and they’re going to do what’s called a leak test, and many of you have actually probably done this without realizing it. But all we’re going to do now is blow air into the system. So if you’ve ever had a flat bicycle tire, and you’re taken the tire in from a car and you want to know of it has a hole in it, you’ll see that you blow that up with air under water. So we’re infusing water now into the patient’s abdominal cavity, and you’re going to see this in a moment. They’re going to infuse, and we’re communicating. This is where the team approach comes in. They’re communicating directly with anesthesia, and they are going to insufflate or infuse air into the little pouch, which will go through the connection that was made by the stapler and into the intestine, and you’re going to see this blow up, and hopefully, we won’t see – hopefully, we won’t see it bubble. We don’t like bubbles. And there, you can see it right now. It’s blowing up. It’s distended. We didn’t see any bubbles. So that – that assures – or goes a very long way toward telling us that we have a complete connection. And that – that form of test lets us feel comfortable that we’re leaving the operating room with what we call and intact connection or an intact anastomosis. What that doesn’t preclude is that down the road, maybe three, four, five days, there could be a blood-supply problem or some other reason that some of that connection could open, and then that would be what leads to a leak. So an oxygen test doesn’t completely rule it out, but it goes a very long way, and as you can see, it’s sort of the best we can do, aside from visual inspection, to tell that this is all okay. They’re going to go down now and do a few other steps, and while they’re doing that, I want to make sure we get to the myriad of questions that have come in. The statistic that’s out there in terms of success after weight-loss surgery is that about 75% of patients who go through this type of operation will lose the weight and keep it off, and this is very much patient-

driven. This anatomy, if taken care of, and if patients follow appropriate recommendations, exercise, and follow up, the vast majority, through a lot of hard work and dedication will be able to lose the weight and keep it off. But about 25% don’t go that route. About 25% actually lose the weight, and then at some point in the future, gain some or all of it back, and a lot of patients are very surprised to hear this. How can you possibly have a stomach the size of the one that you just saw and actually end up taking in enough calories to gain weight back? And several questions have come in asking about stretching of the pouch or mechanisms for failure, and this is something that’s very important for patients to understand. This is not a cureall. This is not magic. I just had a patient today sit in my office shocked to hear that this wasn’t a guarantee. And wherever you go to get information about the surgery, you should have an honest conversation about the team about success and failure and what goes into it. It’s the whole reason that we have advocated here that the institution put their support into a multi-disciplinary program and not just have us exist here as three surgeons doing an operation on our own. All the people that we work with at our institution, all the psychologists, dieticians, the medical doctors, the exercise physiologists are very important. When patients come back a year later and they say, “Thank you, Dr. Shikora, Dr. Tarnoff, Dr. Kim, you saved my life,” I usually respond and say, “Well, I’ll take credit for a safe operation, but everything else really comes down to the patient and their interaction with our program.” 00:47:24 SCOTT SHIKORA, MD: I tell them my mother appreciates that thank you. 00:47:26 MICHAEL TARNOFF, MD: That’s right. And that - -the importance of that really needs to be understood, and as I said, wherever you end up seeking information on this, if you do go that route, you really want to make sure you have a conversation about what’s in place to help me in the short term and what’s in place to help me in the long term. What they’re doing now is utilizing another innovative device known as the endostitch, and this is something that helps us suture inside the abdomen laparoscopically. We’ve done all this through a couple of small incisions, and that’s what’s going to afford this patient the opportunity not only for a early discharge from the hospital but for a better long-term outcome relative to the days that we used to do this through larger incisions. And that’s another point that I think needs to be made. Many surgeons have tried to advocate that this still done open, through an open approach, and they’ll base that argument on the idea that the patients will still go home in two or three days, but that really doesn’t address the idea that there are long-term implications of having laparoscopic surgery that are truly better in terms of a lower risk of other complications that can occur down the road, and those are things you should ask about when you seek consultation for this type of surgery. Some other questions that came in: “Can the stomach pouch you just created get bigger and stretch and therefore the patient won’t lose any more weight?” I alluded to that a little bit earlier, but maybe Dr. Kim, if she’s not too focused on what she’s doing, could answer that one. 00:49:00 JULIE KIM, MD: Generally speaking, the pouches stay about the same size, but it obviously can dilate to some extent if there’s overeating, dietary non-discretion. In general, the pouch expands a little bit. The patient should still feel restriction and be able to maintain their weight loss. 00:49:19 MICHAEL TARNOFF, MD: Another question came in. Dr. Shikora introduced the anesthesiologists. Scott, can you make a comment on some of the anesthetic complications? A specific question came in about whether this was a rapid-sequence intubation, and how do we approach that?

00:49:35 SCOTT SHIKORA, MD: Well, I’d be hard-pressed to answer that with the anesthesiologist right here over my shoulder. I’ll let her answer, and I’ll translate. A lot of it’s respiratory, difficulty getting an airway. We don’t – we don’t have as good information about drug dosing, et cetera, in very overweight people because most of the studies were done on average-sized people, but a lot of it has to do with airways and taking the tube out at the end of surgery, et cetera. Is that right? Am I missing anything? She was a rapid-sequence intubation. All righty, can we get a drain? 00:50:17 MICHAEL TARNOFF, MD: Julie, how about a comment on recovery time from gastric bypass versus lap band, and maybe address both in-patient, out-patient versus the return to work and those issues. 00:50:28 JULIE KIM, MD: Generally speaking, I think the operations take about similar times, the lap band will take about an hour. The bypass takes about 90 minutes. Patients who undergo lap band generally go home the same day. Bypass patients stay two or three days because we’re monitoring them for the potential for different kinds of complications that can occur early on after surgery. In terms of overall recovery, I usually tell patients that with the band, it’s about one to three weeks, and with the bypass, two to four. SO there really isn’t that much difference in the long run between the two. 00:51:01 MICHAEL TARNOFF, MD: Scott, another question: “Where’s all the blood?” 00:51:07 SCOTT SHIKORA, MD: Well, you can get into bleeding during any surgery, whether it’s open, laparoscopic, an appendectomy, a hysterectomy, a gastric bypass. You know, I’d like to brag we were so good we don’t have a lot of bleeding, but generally, this is what most of our laparoscopic cases are like; they’re very, very bloodless, and that’s one of the other benefits of doing it laparoscopically. 00:51:27 MICHAEL TARNOFF, MD: I think that’s a common misconception of any surgery, whether you do it open or laparoscopic. As surgeons, we spend a lot of time trying to stay in appropriate tissue planes and avoiding all the blood vessels and all the blood that’s actually circulating in this patient’s abdomen, and in about 1 to 3% of time, we do encounter bleeding, and we always deal with it. But it is something that comes up, but as Dr. Shikora said, I think the average blood loss that we see with this procedure is really in the range of about 30 to 50 ccs, which is quite minimal. How about a comment on gall-bladder issues post-operatively? Probably a misconception that gall-bladder problems are common. 00:52:08 SCOTT SHIKORA, MD: Well, in the literature, they were represented as common. About 25% of patients will have had their gall bladder out by the time we see them for this type of surgery, and about 20 or 25% would have gall stones if we X-rayed everybody or ultrasounded everybody. At one time, we were more inclined to take out the gall bladder of anybody that had stones even if it never bothered them, and now the field has shifted in most centers such as our to not deal with those gall stones and gall bladders and only deal with it should the patient develop symptoms down the road. 00:52:46 MICHAEL TARNOFF, MD: What they’re doing now is the near-final step of the procedure, is closing the holes that are made in the patient’s abdominal wall. So they’re looking up. Maybe, Julie, you can press on the abdominal wall. So if you press on your abdomen, this is what it looks like on the inside, and they’re actually

just putting some suture around the holes that were made by these – these small, plastic tubes, or what we call trocars. And this is aimed to prevent what’s called a hernia, and a hernia would visible to a patient on the other side of what you’re seeing here, on the skin side, as simply a bulge. So a piece of fat tissue or a piece of an organ would actually work its way up through the little hole and appear as a lump under the skin or a mass. 00:53:32 SCOTT SHIKORA, MD: Mike, if you want to just point out – 00:53:35 JULIE KIM, MD: Those are adhesions. 00:53:37 MICHAEL TARNOFF, MD: These are adhesions. This patient – what was her prior surgery? 00:53:40 SCOTT SHIKORA, MD: C-Section. 00:53:42 MICHAEL TARNOFF, MD: If you’ve ever had a C-Section or if you’ve had a hysterectomy or any kind of pelvic surgery, this is what it looks like on the inside. This is scar tissue. So that is a little bit of fat on the inside that is now stuck to the undersurface of the incision that was made, and this can complicate our ability to do surgery – additional surgeries because it can obscure the anatomy. One of the things that we’ve learned here with the considerable experience that we’ve had with any form of laparoscopic surgery is that patients who have had prior surgery can still have a laparoscopic approach. So as you go talk to physicians or try to get information on weight-loss surgery, you certainly should understand that prior surgery is not a reason not to have a minimally invasive approach. “Do you go home with drains or are they removed before?” Generally speaking – you saw this patient had a drain placed, a plastic tube, and the general approach here is to leave that in for about two days. This patient – tonight’s Wednesday. This patient will probably go home Friday. That drain will be taken out before she goes home. So she’ll basically just go home on her own with some incisions that are hearing. “Sorry, I’m very interested in the anesthesia point of view. Since you’re working in the patient’s stomach, how do you perform the anesthesia in this case?” Well, maybe we can just show a little bit more of the room, and Dr. Wyrm, perhaps you can wave so we can just show where anesthesia is. But the patient is – the patient’s head is obviously above the drapes. Maybe you can just point down, show where the patient’s head is. Just give us a little point where the patient’s head is. And she was induced under general anesthesia. So in simple terms, they use medication, basically, to put the patient to sleep and then to paralyze the patient. And because of that, a tube is inserted in the mouth and down into the windpipe, and then with use of an anesthesia machine, the anesthesiologists have been breathing for the patient the whole time we’ve been in here. They’ve been monitoring all of her vital signs, and they really take control over all the patient’s vital systems and keep the patient paralyzed so we can do what we need to do. And it’s a lot of interaction between us and them. And another thing that probably gets missed when you go for a consultation for weight-loss surgery is a discussion of the experience of the anesthesia team, and it’s something that we’re very fortunate to have here, but we have talented anesthesiologists that are very skilled at dealing with morbidly obese patients and the challenges that they present from an airway perspective and from an anesthesia perspective, and clearly that’s something that you want to ask about and pay attention to as you look to get more information on weight-loss surgery – any surgery, really, for that matter. They’re just about done with the procedure. They’re doing the final step, which is just closing the skin. This patient will have six –

I don’t know if we can get a view of the patient’s abdomen, but this patient will have six small incisions. That one is actually the largest, and if there’s a way to maybe pan across and – is there a way to get a wider view? There we go. So a couple of small incisions, cosmetically, this is a very appealing way to have surgery. It’s certainly the gold-standard approach for most general surgical procedures nowadays, gall bladders, splenectomy, just about most of the operations we do, we try to do with the laparoscopic of minimally invasive approach, not just for cosmetic reasons, but for access reasons. You were all able to watch what we did. You had the same view that we have here in the operating room, and you can see that it really – with all the technology, gives an outstanding view of the inside of the abdomen and of the anatomy, and it’s a view that I actually think is superior than whet you get when do an operation open. We spent a lot of time talking about laparoscopy. I would say about 98% of patients in our program get a laparoscopic approach, just like you saw, even if we get into bleeding or some other problem. If you do a lot of this, you get the skills to deal with things that come up and maintain a laparoscopic approach. Despite that, a few percent do need to be converted, and every now and then, we do have to remove the ports and make an incision and deal with something in an open fashion. Because the goal of this is to do a successful, safe procedure and get you home in a few days, and that’s really what we’ve focused our efforts on doing. I don’t have anything else specifically from the OR. I do want to ask Dr. Shikora and Dr. Kim to comment. One of the other questions that came in is, “Why do you do this? What made you choose bariatric surgery? And where does it fit in to your surgical practice?” And maybe both of them can give us a comment on that, and then maybe I’ll comment as well, and then we’ll turn it back over. 00:58:37 SCOTT SHIKORA, MD: Well, like most of us bariatric surgeons, this wasn’t what we set out to do in the beginning, and what I found is that as I experienced this, I could not find anything else in medicine as rewarding personally because we have such a positive impact on these patients’ lives. You had already alluded to the improvements in health and how poor the quality of life is prior to surgery and how meaningful and fulfilling it could be after surgery. And patients are very grateful for that opportunity. A lot of them call the operative date their new birthday, and they reflect their gratitude to their relationships with us, and I just find that extremely rewarding and worthwhile. 00:59:22 MICHAEL TARNOFF, MD: Dr. Kim? 00:59:24 JULIE KIM, MD: I think I liked the simple things. You know, you get to do this job, and you have a patient come to you post-operatively, tell you for the first time that they could have their children hug them all around or they could take a flight on a – on – on – on a plane and not have to use the extra-wide seat belt, and it’s those simple things that really touch you and, I think, make this worthwhile. Most of our patients are women, and I think it’s something nice for me to be able to do and give back. 00:59:51 MICHAEL TARNOFF, MD: And I can just echo for myself what Julie just said. There’s really no one procedure that we do. We do a lot of different types of surgery, but there’s no one procedure that has such a dramatic effect on both lifestyle and health, and many a bariatric surgeon have commented on the way that this single intervention can effect quality of life in dramatic ways and affect health in dramatic ways, and one simple procedure – not simple, but one procedure translates into a resolution of diabetes and high blood pressure and sleep apnea and heart disease and all the other health problems, let alone the quality-of-life factors and the things

that Julie just mentioned, the ability to get a hug all the way around or sit in a seat or just walk outside and not feel as self-conscious, and that, I think, for all of us is rather rewarding. Before we leave, we want to get a few final comments from some of our patients, and I think you’re going to hear that now. It’s been a pleasure getting to do this, and it’s been a privilege to do it, and if any of you have any questions or have any more follow-up that you’d like from any of us, we’re all available to do that. 01:00:58 JULIANNA PACHECO: I feel great today. This outfit – this is the first day I’ve ever worn this suit, and it’s a size 14 , and I used to be a size 36. So that feels great. That feels great not to have to go into the special store anymore. It feels great to enjoy fruit. I feel great. I have a lot of energy. I love playing with my kids. I look forward to getting on the floor with them, playing with the toys and stuff, and I look forward to going to the gym. We fight about who gets to go to the gym. And some couples fight about money. We fight about going to the gym. 01:01:34 RICK PACHECO: One of our prizes, so to speak, is once we both reach our goal is to take a trip and renew our wedding vows. When we got married, we were both very heavy, and I was given one choice of a tuxedo to wear. 01:01:51 JULIANNA PACHECO: And I had two choices of wedding dresses. 01:01:53 RICK PACHECO: And Julie had two choices for wedding gowns, and now we’re going to be able to choose and pick whatever we want. And it’ll be just the two of us on a beach somewhere and maybe some close friends, but we’re going to do it the way we want to, and we’re going to wear what we want, and we’re going to renew our new lives together at that time. 01:02:20 ANNOUNCER: This has been a laparoscopic gastric-bypass surgery performed at Tufts New England Medical Center in Boston, Massachusetts. To obtain more information, to make an appointment or make a referral, please click the buttons on your screen. 01:02:42 [ END OF FILE ]