The University of Texas Southwestern Medical Center

| July 12, 2013

Dallas, Texas

by Michael J. Lee, MD

Dr. Michael J. Lee is Director of Metabolic & Bariatric Surgery and Advanced GI MIS/Metabolic & Bariatric Fellowship Co-Director at UT Southwestern Medical Center in Dallas, Texas.

Bariatric Times. 2012;10(4):32–33

FUNDING: No funding was provided.

DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.

Welcome to the University of Texas Southwestern Medical Center
The bariatric program at The University of Texas Southwestern Medical Center (UT Southwestern) provides comprehensive treatment for obesity. The center is a regional and national referral center for bariatric surgery and revisional bariatric surgery and has achieved many milestones, including:
•    First to perform the laparoscopic Roux-en-Y gastric bypass (RYGB) in North Texas in 1999
•    First to perform laparoscopic adjustable gastric banding (LAGB) in North Texas in 2001
•    First to perform gastric banding with single-incision laparoscopic surgery (SILS) in North Texas in 2008
•    Full accreditation by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)
•    Designation as an ACS Accredited Regional Educational Center for Surgeons for the Southwestern Center for Minimally Invasive Surgery (SCMIS)

Our Staff
Our multidisciplinary team includes the following:
1.    Bariatric surgeons. Michael J. Lee, MD, Director ; Daniel Scott, MD; Mark Watson, MD; and Nancy Puzziferri, MD, MS
2.    Mid-level medical providers. Anna Smith, MPAS, PA-C, Program Coordinator, and Leah Tan, MPAS, PA-C
3.    Residents and fellows. As the largest General Surgery residency program, over 80 residents rotate through the bariatric rotation. We train one postgraduate fellow per year.
4.    Registered dietitians. Bonnie Hudson, RD, and Taylor Tran, RD

5.    Support staff. Grace Kim, RN, Bariatric Nurse, and Pedro Cervantes, Financial Advisor
6.    Psychologist. Martin Deschner, PhD

Our Facility
Our Outpatient Surgery Center (OSC) building opened in 2010 with a multidisciplinary outpatient approach in mind. The current main hospital, St. Paul University Hospital, is a major acute care multispecialty 333-bed hospital with continuous call, emergency room, and intensive care unit (ICU) coverage. All facilities are fully compliant with the latest MBSAQIP standards. In addition, a new University Hospital, which will fill over 400 beds and double the size of the operating and emergency rooms, is set to open in late 2014.

We have equipment that can accommodate up to 1,200 pounds, including shower chairs, extra-large chairs in the waiting areas supporting up to 750 pounds, hospital beds, scales, wheel chairs, floor-mounted or structurally supported toilets supporting 1,200 pounds, extra-wide doorways, private rooms, blood pressure cuffs, abdominal binders, gowns, walkers, sequential compression devices (SCD), patient transport systems, and a bariatric drop-arm commode that accommodates 800 pounds.

Waiting rooms have a discrete mix of average sized chairs as well as bariatric chairs to maintain sensitivity toward bariatric patient needs, and all exam rooms are spacious and equipped with bariatric chairs and exam tables that are able to accommodate our bariatric population.
The operating room tables accommodate patients up to 1,000 pounds. We have a HoverJack (HoverTech, Bethlehem, Pennsylvania) system in place that can lift up to 1,100 pounds. High-definition laparoscopic equipment is available in the bariatric dedicated operating rooms.
an accredited center

Potential patients expect the highest level of care from UT Southwestern, and expect the highest levels of accreditation.
The OSC building was built with forward expansion in mind and recognition for specialized multidisciplinary care for patients with morbid obesity. UT Southwestern has been pioneering bariatric surgery in North Texas since the early 1990s, so the accreditation process was not difficult.

Patient Adherence and Long-Term Follow Up
The program sees all patients, including tertiary referral for high-risk patients and also a large proportion of Medicare patients. There are well over 1,000 visits to our bariatric clinic annually.

Bariatric patients are seen every three months following the initial postoperative visit during the first year, every six months during the second year, and yearly after that. Follow ups for patients are scheduled prior to surgery and patients are reminded prior to discharge. Patients are also encouraged to enroll in UT Southwestern’s e-mail system through the electronic medical records (EMR) function in MyChart® (Epic Systems Corporation, Verona, Wisconsin). A trained, dedicated data entry manager also manages the accreditation bariatric database to ensure everyone has follow up visits. We not only keep record of excess weight loss but also an ongoing database for complications and clinic visits to ensure compliance.

The biggest complications in terms of patient adherence include permanent nutrition deficit sequelae due to lack of adherence or refusal to follow diet or vitamin guidelines, which affect a patient’s long term health or pregnancy. As a large, multidisciplinary center we stress the importance of the postsurgical care as much as the preoperative and operative care.

Managing Patient Care
Patients receive comprehensive education about preoperative, operative, and postoperative care during their initial information seminar. The seminar is 90 minutes and led by a bariatric surgeon, a physician assistant, dietitian, and a financial counselor. All patients that live within 100 miles of our center must attend this mandatory seminar during which we explain the bariatric operations, the logistics of the program, paperwork involved, HIPAA (The Health Insurance Portability and Accountability Act of 1996) guidelines, the role of the dietician and weight management program as well as realistic expectations and recovery. Like most programs, patients see our team at least 3 to 6 more times before surgery and are given additional study guides, hand-outs, and plans to ensure full education.

Our Equipment and New Technologies
UT Southwestern has invested $50,000 to purchase a transnasal endoscope from Vision Sciences (Orangeburg, New York) to provide screening and diagnostic transnasal upper endoscopy. This new technology enables the bariatric surgeon to perform endoscopy in the clinic setting with topical anesthesia and avoid risks associated with heavy sedation or even general anesthesia.

Scheduling and Inventory
We use Epic Systems Corporation EMR between all the hospitals at UT Southwestern so that all clinics can communicate effectively with a singular platform.
Terri-Brown Lamb schedules appointments for the center. Shelby Holt, MD, our Multidisciplinary Clinic Director, oversees all inventory and staffing. Renee Bailey, operating room supervisor, handles purchasing of operating room equipment and supplies. Laura Meier is our bariatric operating room equipment liason.

Patient Assessment
Patients undergo an extensive work up when seen for initial consultation. Their medical history is taken into consideration and tests and clearances are ordered as needed. We have a protocol in place to determine appropriate pre-operative work up for each patient and a multidisciplinary review, which includes the team mentioned previously, to discuss each patient prior to surgery. Patients see a physician assistant several times as well as a dietician to discuss current and future nutritional counseling.

As an academic medical center in a non-profit organization, managed care has not dramatically affected the bariatric program. Most patients have financial responsibility through third-party insurance carriers and Medicare.

We have a dedicated bariatric team with four bariatric surgeons to provide continuity of care and continuous on call coverage.

Patient and Staff Safety
We have protocols listed in our comprehensive online system accessible by staff, as well as postings around facility with regards to safety. We have a HoverJack system, which can lift up to 1,900 pounds and provide instructions to all staff members for use in case of a patient fall. All employees are educated to never lift patients alone. We have wheelchairs with designated weight scales for patients to be transported as well. All bariatric equipment is coded with a discrete number system so that employees may find appropriate weight-bearing equipment with ease in times of urgency.

Staff Training
Quarterly half-day lectures covering bariatric surgery essentials, nutrition, patient transfer and safety as well as bariatric sensitivity are given to all employees.

Emerging Trends
Bariatric surgery is the most effective treatment for obesity and the metabolic effects from obesity, including diabetes. This has been proven in randomized, controlled trials and more patients and physicians are understanding this. As far as emerging technologies, I think devices such as the endoluminal sleeve, intragastric balloon, and medications will serve better as adjuncts helping patients lose weight to better prepare them for bariatric surgery.

UT Southwestern has just purchased a transnasal endoscope, which will allow the surgeon to perform his/her own endoscopies in an outpatient setting without conscious sedation or general anesthesia.

Patient Cases
We have seen several interesting bariatric patient cases at UT Southwestern.

Case 1. A 40-year-old man was scheduled for an elective cholecystectomy. He had a previous laparoscopic RYGB two years prior to presentation and lost over 130 pounds. His body mass index (BMI) was 23kg/m2. He presented to the emergency department two days prior to his elective cholecystectomy with continuous right upper quadrant pain and no signs of peritonitis. His abdomen was nondistended. A laparoscopic cholecystectomy was planned, but he had two liters of purulence free in his abdomen. He was then opened and found to have an internal hernia through the small bowel mesentery defect and mesenteric venous congestion. His mesentery had an unusual gelatinous quality. In addition, his gallbladder was severely distended with stones and he had a 2cm fecalith in his appendix with inflammation. Both were removed and the abscess was evacuated. The patient was discharged one week later and, as of his two-month follow-up appointment, is doing well. I think he had ascites fluid from the venous congestion and third spacing from the incarcerated internal hernia. Interestingly, I think the fluid may have been infected from cholecystitis/appendicitis and due to his malnourished state, his immune response and pain response were very unusual.

Case 2. A 65-year-old man had a laparoscopic RYGB 10 years prior to presentation and was transferred to my care due to a 3cm bleeding marginal ulcer. He was told he had a major complication but was unsure what complication he had at his initial operation. He had no follow up due to his original surgeon’s early retirement. He had been treated conservatively for a marginal ulcer with proton-pump inhibitors (PPIs), however continued to smoke one pack of cigarettes per day. While undergoing a cystectomy for bladder cancer, he developed a deep vein thrombosis (DVT)/pulmonary embolism (PE) during his hospital stay and was anticoagulated. He bled from his marginal ulcer, which required resuscitation and an exploratory operation. His gastrojejunostomy was difficult to expose under the liver. In fact, there was a contained abscess cavity at his previous gastrojejunostomy anastomosis embedded into the liver. Although difficult and tedious, his gastrojejunostomy was revised and a feeding tube was placed. The patient was discharged two weeks later and, as of his nine-month follow-up appointment, has been doing well.

A Unique Facility
Our bariatric program is an integral component of UT Southwestern, which is the largest medical center in North Texas. UT Southwestern has invested in a new outpatient multidisciplinary clinic and is also building a new larger main hospital to better accommodate the community.
In addition, UT Southwestern consistently ranks at the top. Recently, UT Southwestern Medical Center ranked number one as “The Best Hospital in Dallas-Fort Worth” by U.S. News & World Report’s America’s Best Hospitals Ranking in 2011.

Staff members of the UT Southwestern team pose for a picture

UT Southwestern outpatient surgery center

UT Southwestern University Hospital

Waiting area

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Category: Bariatric Center Spotlight, Past Articles

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