Bariatric Center Spotlight
This column is dedicated to featuring accredited bariatric centers around the world, with a focus on their facilities, staff, statistics, processes, technology, and patient care.
This month: Sentara Comprehensive Weight Loss Solutions
by Stephen D. Wohlgemuth, MD
Dr. Wohlgemuth is Medical Director of Sentara Comprehensive Weight Loss Solutions in Norfolk, Virginia.
Bariatric Times. 2015;12(11):38–40.
Welcome to Sentara Comprehensive Weight Loss Solutions
At Sentara Medical Group, we are fortunate to have developed a totally comprehensive, all-inclusive center to manage patients struggling with the insidious disease of obesity. Our process includes thorough observance of ‘The Sentara Promise’ to treat all patients with dignity and respect, respond to their questions and needs and engage them as informed partners throughout their weight loss journey. In our 17,000-square-foot center, we have 15 fully wired exam rooms to offer both medical and surgical options for weight loss. We have a fully integrated conference room, which can accommodate 100 people, a 500-square-foot exercise facility and a 300-square-foot retail space. Every facet of a patient’s care can be accomplished on-site.
Stephen D. Wohlgemuth, MD, is the Medical Director of Sentara Comprehensive Weight Loss Solutions. Dr. Wohlgemuth is also an Assistant Professor of Clinical Surgery at Eastern Virginia Medical School. He is certified by the American Board of Surgery and a member of the following associations: the Southern Medical Association, Norfolk Academy of Medicine, Virginia Bariatric Society, Society of Critical Care Medicine, Virginia Medical Society, American Society of Bariatric Physicians (ASBP), The Obesity Society (TOS) and the American Society of Metabolic and Bariatric Surgery (ASMBS). He is past president of Virginia Bariatric Society and is a fellow of the American College of Surgeons (ACS) and ASMBS. Dr. Wohlgemuth is currently involved in numerous research projects dealing with bariatric surgery and has presented his research at numerous national medical meetings, such as Obesity Week and Obesity Weekend. After a broad-based general surgical career he has made bariatric surgery and development of this comprehensive center his main focus. He has now performed over 2,000 bariatric procedures and is actively involved in the newly formed MBSAQIP Center of Excellence Program.
Mark A. Fontana, MD, is Surgical Clinical Director of Sentara Comprehensive Weight Loss Solutions. Dr. Fontana has performed more than 1,000 laparoscopic gastric bypass surgeries and LAGBs. He is currently in the process of developing the general and bariatric robotic programs. He is certified by the American Board of Surgery and is a Fellow of the ACS. Dr. Fontana is also a member of the ASMBS. His emphasis is on safe surgery, preoperative patient education and selection, as well as long-term follow up of his patients for optimal success.
Caren D. Beasley, MD, is Medical Clinical Director of Sentara Comprehensive Weight Loss Solutions. As the Lead Physician of the Medical Bariatric program at Sentara Comprehensive Weight Loss Solutions, Dr. Beasley specializes in treating patients with obesity with serious medical complications. Her evidence-based approach integrates behavior modification with specific dietary and exercise guidance, which are completely customized to patients’ individual health needs. Dr. Beasley is a member of American Academy of Family Practice, ASBP, and The Obesity Society (TOS).
Ninoska Peterson, PhD, is the Bariatric Psychologist for Sentara Comprehensive Weight Loss Solutions. Dr. Peterson’s role is to provide psychological evaluations for potential bariatric surgical patients and provide psychological support for medical and surgical patients at various stages of their weight management program. Dr. Peterson is a licensed clinical psychologist. She is a member of the Virginia Bariatric Society, the ASMBS, the American Psychological Association, and the Society of Behavioral Medicine.
Erick M. Vitug serves as Director of Operations of Sentara Comprehensive Weight Loss Solutions. Lola Wilson is the Practice Manager and Jeanne Sanders is the Bariatric Program Coordinator.
Sentara Comprehensive Weight Loss Solutions embraces a multidisciplinary approach. Our team includes the following:
• 4 Bariatric Surgeons (2 full time, 2 part time)
• 1 Medical Bariatrician
• 1 Bariatric Psychologist
• 3 Advanced Practice Clinicians
• 1 Director of Operations
• 1 Practice Manager
• 1 Certified Bariatric Nurse Coordinator
• 3 Nurses (1 RN, 2 LPNs)
• 3 Medical Assistants
• 1 Clinical Exercise Specialist
• 1 Registered Dietician
• 2 Patient Navigators
• 1 Insurance Coordinator
• 1 Research Coordinator
• 1 Patient Care Representative
• 1 Retail Associate
Our facility is 17,000 sq. ft. dedicated to the management of the bariatric patient. Furniture in the waiting rooms and other public spaces is sized for the bariatric patient. Every exam room has a table that can accommodate any patient of any size. Tables are low to the floor so patients do not have to climb to get onto them. Bathrooms are also equipped for the bariatric patient.
We are fortunate to have a comprehensive bariatric retail store that stocks multiple vitamin and mineral lines as well as a full complement of protein supplements, meal replacement items, snacks and beverages. We also offer books, pedometers, scales and fitness tracking devices. All of the items in our store are competitively priced and really available as a convenience for our patients and the community at large.
All of our surgeries are performed at Sentara Norfolk General Hospital. The operating room at Sentara Norfolk General Hospital is fully staffed according to ASMBS and ACS Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MSBAQIP) Center of Excellence guidelines for patients up to 1,000 pounds. We go above and beyond the MBSAQIP requirement by offering a specialty pod for patients to recover. The bariatric patient pod has six beds specifically designed and outfitted for postsurgical patients. It also features bariatric seating and extra wide doors to accommodate the extra wide beds and stretchers. Every room in the center has an overhead lift for patients who need help getting in and out of bed. All nurses are specialty trained to care for bariatric patients.
Procedure Statistics and Patient Demographics
Our team consistently performs over 350 surgical cases a year. As with most bariatric programs, 80 percent of our surgical patients are women. The average BMI is 48, and the average age is 47. Table 1 shows the percentage and types of surgical procedures performed to date. From 2008 to 2010, gastric bypass made up the majority of procedures (45–56%) followed by LAGB (35–48%). In 2011, we began performing laparoscopic sleeve gastrectomy (LSG). Since then, the percentage of LSGs has steadily increased from 30 to 88 percent. Both bypass and LAGB procedures have drastically decreased as LSG gained in popularity at our center and throughout the world.
We continue to have excellent outcomes. In the most recent 2014 Semiannual Report from the MBSAQIP all of our sleeve outcomes were as expected with four categories being exemplary. Since beginning our laparoscopic program 15 years ago we have a mortality rate of 0.1% which is below the national average.
Achieving Accreditation Designation
Our program was the second program in Virginia to receive the American College of Surgery designation as an Adult and Adolescent Bariatric Center of Excellence (COE). We have undergone two three-year reaccreditations, and are undergoing our site visit for the MBSAQIP program before the end of 2015. We have fully endorsed the COE process from the very beginning. The process reinforced and highlighted all the good things that we were doing, as well as areas for improvement. Dr. Wohlgemuth was actively involved in the ACS BSCN program as a reviewer and advisory board member, and now serves on the verification subcommittee of the advisory board.
We explain MBSAQIP accreditation to our patients at our information sessions, which we offer online and in-person. We are also completely HIPAA compliant.
Patient Engagement and Assessment
Patient engagement begins at one of our six monthly public information sessions. From there, all interested patients are scheduled for their initial surgical consultation with one of our four bariatric surgeons. A standard history and physical is performed with special attention to appropriateness for entry into our bariatric surgical program.
Our bariatric trained psychologist meets with the patient to assess whether there are any major psychological or behavioral issues that may impede success. If the patient has obesity related comorbidities, such as obstructive sleep apnea (OSA), cardiovascular disease, or type 2 diabetes mellitus (T2DM), we refer them to appropriate specialists. A bariatric anesthesiologist sees high-risk patients before undergoing any weight loss operation. All clinical members of the staff meet once a month to discuss difficult patient cases. We call this our “red flag” meeting.
We have a number of patients who qualify for surgery according to the currently accepted NIH guidelines but don’t have insurance coverage. These patients have the option of entering our self-pay program or entering into our comprehensive medical weight loss program run by our board certified medical bariatrician, Dr Beasley.
Additionally, many patients considered too high risk due to excessive weight are referred to the medical side for aggressive weight loss prior to entry into the surgical program.
Patient Adherence and Follow up
We believe that our team members and patients should set realistic expectations for weight loss prior to surgery. We tell our patients that they are our patients for life, not just during the preoperative period. We encourage them to come back yearly after the two-year mark. We find that most patients do adhere to follow-up appointments during the first postoperative year; however, there is a decline in adherence after one to two years.
Long-term follow-up continues to vex all COE programs and we are no exception. We are very assertive and try to contact patients who don’t follow up via regular mail as well as email. We also try to come up with new and creative ways to optimize follow up via social media as well as offering incentives such as discounts at our bariatric retail store to patients who keep their yearly appointments.
Our Equipment and New Technologies
We are a comprehensive facility. We have classroom, clinic, and exercise and retail spaces. Highlights include the full-service exercise facility; blood draw station for labs for research; and dedicated bariatric psychologist, exercise specialist, and dietitian. The cross over and synergy with our medical bariatrician is also very important.
We have a unique commercial three-dimensional body scanner whose origins are in the custom clothing industry. The scanner creates a 3D archival image with consistent reproducible measurements that allows us to track patients’ progress and to do studies of body-image assessment. It’s a real motivator to patients as they see the results of the scans. We are currently working closely with Dr. Walter Poires at East Carolina University to develop a better way to categorize obesity using patients’ unique body shapes, volumes and surface area.
We use a patient tracker and data management tool available commercially from Exemplo. We have entered every single patient we have operated on since our first laparoscopic bypass in fall, 2000. We have two patient navigators who schedule the procedures and use the patient tracker and data management tool to track outcomes including postoperative comorbidities and weight.
Cost and Efficiency
As employed physicians, we feel we have a responsibility to be as cost efficient as possible in the operating room. We are continually reviewing our outcomes as well as the literature to either eliminate unnecessary items or change to more cost effective products. As an example we have been able to reduce the cost of a sleeve gastrectomy since we started 4 years ago by $763 per case.
Patient and Staff Training
In the operating room, we have special transferring devices that help us move larger patients. In the bariatric patient pod at Sentara Norfolk General Hospital, we have lifts in all the rooms. All members of the clinical team are trained in patient safety. Every new nurse at Sentara must complete an educational module that covers sensitivity training and patient transfer. There is mandatory refresher training for all staff as well as multiple in-services every year for all staff by our BSCN Jeanne Sander. Additionally we have an annual CME/CEU conference on obesity related topics available free of charge for all floor and OR staff.
In general, patients looking for significant weight loss coupled with good resolution of comorbidities catapulted the sleeve into its current position of popularity. We see a decrease in use of the LAGB. Our practice illustrates the worldwide popularity of LSG. So far this year, 88 percent of procedures performed were LSG, and 15 percent were gastric bypass.
We are starting to develop a robotic bariatric surgical program with the daVinci robot (Intuitive Surgical, Inc., Sunnyvale, California) as well as evaluating the newly approved intragastic balloons and vagal stimulating device. We have historically had a very conservative approach to the newest technologies trying to balance providing our patients with the latest treatment options, but only after there are solid supporting clinical data.
Interesting and Challenging Cases
Case 1. A 63-year-old man with a non-ischemic cardiomyopathy and ejection fraction of 10 percent was in need of a cardiac transplant. Unfortunately, his BMI (45.9kg/m2) made him ineligible according to our transplant center criteria. He had a left ventricular assist device placed as a temporizing measure and after extensive evaluation, he underwent an uneventful sleeve gastrectomy in July 2013. Within 12 months, he had lost 100 pounds and decreased BMI to 30kg/m2. In November 2014, 18 months post sleeve gastrectomy, he had a successful heart transplant and continues to do well.
Case 2. Another challenging case was a 41-year-old man diagnosed with early stage prostate cancer. After much discussion with his urologist, he wanted to pursue a robotic prostatectomy but his BMI (46kg/m2) made him ineligible. The bariatric team initially evaluated him in July 2010. We were able to expedite his pre-operative process and performed a gastric bypass on August 2010. Within three months, he had lost 40 percent of his excess weight and his BMI decreased to 36kg/m2, enabling him to undergo a successful robotic prostatectomy in December 2010. He is now four-and-a-half years postsurgery. He has lost a total of 135 lbs, 77 percent excess body weight, and now has a BMI of 27kg/m2. He has had complete resolution of his hypertension and he is cancer free with a normal prostate-specific antigen.
Case 3. One of our most challenging cases was a 24-year-old women who underwent a straightforward sleeve gastrectomy only to have a proximal leak on postoperative day 10. Despite aggressive nonsurgical management with multiple stents, percutaneous drainage, and hyperalimentation, we were unable to get the leak to resolve. After three months, we were able to perform a combined radiologic, gastroenterologic, transoral placement of an anal fistula plug made of biologic material to plug the leak from inside the sleeve. This afforded complete closure with resolution of postoperative feedings.
She is now 4 years postopertive with excellent maintained excess body weight loss of 82 percent.
A Unique Facility
Our size and scope make Sentara Comprehensive Weight Loss Solutions a unique facility. We have endocrinologists from Eastern Virginia Medical School (EVMS) and a research partnership with EVMS’s Strelitz Center for Diabetes. We are one of a select few programs with everything needed for bariatric patient care under one roof: medical, surgical, psychology, exercise, nutrition, a retail store, 3D body scanner, and a conference room with space for up to 100 people. We are confident that this model represents the future of obesity management and are excited to be able to offer this to the patients of southeastern Virgina/ northeastern North Carolina.
For more information on Sentara Comprehensive Weight Loss Solutions at Sentara Norfolk General Hospital, visit http://sentaraweightloss.com/.
PHOTOS OF OUR CENTER
FUNDING: No funding was provided.
DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.