Dr. Gagner Featured in General Surgery News Article on Stomach Intestinal Pylorus-Sparing Surgery

 Recently, Dr. Gagner was featured in a General Surgery News article entitled “Stomach Intestinal Pylorus-Sparing Surgery” also known as SIPS. The article is a round-table style interview with physicians, surgeons and experts on the topic, a surgery that has been at the forefront of discussion in the field. This new technique is based on a modification of the duodenal switch procedure, and in some practices it accounts for more than 40% of bariatric surgeries performed based on information presented at the 2016 Minimally Invasive Surgery Symposium.

 What is the duodenal switch?

 The duodenal switch (DS) is composed of a restrictive part, a gastric sleeve reduction procedure, and a malabsorptive part also known as a biliopancreatic diversion, which decreases absorption of fat mainly.  Both components help those with obesity and remove excess weight, especially the body fat compartment.

 Dr. Gagner’s Key Points

Dr. Gagner states that in the U.S there are many variations of the duodenal switches and that SIPS is just another variant being performed, which is very similar to what has been done for the last 25 years. In SIPS, there is only one anastomosis (connection), and therefore technically simpler and shorter in anesthesia duration.

SIPS, preserves a normal emptying of the stomach, because the pyloric valve, a muscle sphincter between the stomach and intestine is intact. This avoids dumping syndromes and severe swings in blood sugar.  It is a procedure that is either done in super-obese, diabetics (Type-2) or in those who have weight regain after the popular sleeve vertical gastrectomy. The procedure was initiated by surgeons in Madrid more than 5 years ago, and now is becoming more and more popular in the USA and Canada.

 He also explains informed consent in the interview – the concept of explaining what you intend to do with the patient. It is important to have written informed consent whether a classic intestinal reconstruction approach is being taken or a SIPS procedure, as the two procedures could present different side effects. However, Dr. Gagner states that the slight modifications between the two procedures will not make a big difference to the overall outcome.

 For instance, the classic duodenal procedure might affect the frequency and quality of bowel movements (being more frequent and looser) but in terms of micronutrient deficiencies, it will provide the same results as SIPS .This makes the difference between the two procedures such a small change that it should not need approval from the institutional review board.

Dr. Gagner offers SIPS as part of his services at Clinique Michel Gagner. If you or anyone you know could benefit from this procedure, get in contact with us to make an appointment today.

 

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Dr. Michel Gagner Elected to Executive Council of ASMBS

Recently, Dr. Michel Gagner was elected to the executive council of the American Society of Metabolic and Bariatric Surgery (ASMBS) as a Member-at-Large. The ASMBS is a society known for its leadership, organization, educational and support programs for surgeons and integrated health professionals. Their mission is to improve public health and wellbeing by lessening the burden of obesity and its related diseases worldwide.

Contributions

Dr. Michel Gagner’s work has been recognized by the ASMBS for his contributions to metabolic and bariatric surgery with the work he has done in Canada, particularly at Clinique Michel Gagner, along with the number of years he’s spent in the U.S. working for various medical institutions.

Some of the institutions include:

  • The Cleveland Clinic Foundation – where he co-founded the Minimally Invasive Surgery Center (1995-1998).
  • Mount Sinai School of Medicine in New York – where he was appointed the Franz Sichel Professor of Surgery and the director the Minimally Invasive Surgery Center’s New York location.
  • Weill Medical College at Cornell University – where he was the Professor of Surgery and Chief of the Section of Laparoscopic and Bariatric Surgery.
  • Chair of Surgery of the Mount Sinai Medical Center in Miami.
  • Florida International University – where he worked (and still is) as a Professor of Surgery.

On top of these accomplishments, Dr. Gagner has published over 400 journal articles, countless chapters and ten books about minimally invasive surgery. He has also been a visiting professor in over 60 institutions across 49 different countries.

Going Forward

Now, with his new role, he will work alongside executive members of ASMBS to continually improve the quality and safety of care and treatment of people with obesity.

This includes:

  • Working on initiatives to advance the science and understanding of metabolic and bariatric surgery.
  • Taking part in communication aspects between health professionals that work with patients who are obese and suffer from related conditions.
  • Work with a recognized authority and resource on metabolic and bariatric surgery.
  • Continue to advocate for health care policies, patient access, quality, prevention and the treatment of obesity.
  • Contribute to educational and professional needs within the diverse membership community.

ASMBS has roughly 4000 members, which are comprised of practicing general surgeons and integrated health care professionals concerned with the field of metabolic and bariatric surgery. They contribute to an official scientific journal called Surgery for Obesity and Related diseases (SOARD), which contribute peer-reviewed manuscripts and data about the techniques and treatment of obesity, and Dr Gagner is an associate editor of this journal.

 

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The Growing Risks of Medical Tourism

Travelling abroad for medical care, also known as medical tourism, has been steadily growing over the past few years. Many people are flocking to other countries to seek medical care because various reasons and circumstances have made it a viable option for treatment.

Why are people doing it?

According to a recent article written by the Canadian Medical Protective Association (CMPA), there are many factors that contribute to why people are looking for medical care outside of their primary home jurisdiction.

The three main reasons are:

  • Long wait times
  • Procedures or treatments are too costly
  • Treatments are unavailable

Another key reason that medical tourism as an industry has flourished is due to globalization. This sector has been able to expand because many countries are actively seeking people from overseas (medical tourists) to experience their medical care. For example, many Asian countries, Middle Eastern and Latin American countries have developed their infrastructure and facilities specifically to bring people from abroad to their hospitals. With the Internet and technology as a whole, it is easy to access this knowledge through third party sites, book appointments, find a broker, find accommodation and make travel arrangements – which is why many people are going for this route.

The improvement of guidelines and standards of accreditation for these destinations have also significantly spiked the growth of medical tourism. It’s true that many people come to Canada on their visas or visiting permits to receive medical care. However, the number of Canadians seeking medical care abroad – roughly 52, 513 people in 2014 –is higher than those who are coming in for treatment on Canadian soil.

The Risks

The risks are presented to the physicians who are liable to give their patients information on out-of-country treatments and referrals. There are a lot of problems however, in ensuring that the information about procedure success rates at facilities are abroad are reliable and line up with the treatment that their patient is going to get.

Many physicians do not feel comfortable in giving a referral if they are unaware of the procedure’s risk and benefits itself, or if they question the reliability of the source.

Once a physician does provide professional advice to advocate for the procedure abroad, this puts them in the position of a duty of care – a legal obligation that is imposed on any physician to ensure that their care does not put their patient in harm’s way. It is the first element that must be established to proceed with an action in negligence. This leaves a physician in a vulnerable position of having legal action against them in the foreign jurisdiction. This also affects their ability to have help from CMPA on their case.

Finally, many patients also receive out of country procedures that are unknown, illegal and untested in Canada resulting in little to no documentation of the procedure. Canadian physicians will have a hard time following up or tracing harmful symptoms if they don’t have any idea what the procedure really entailed, affecting the continuity of care.

This is particularly pertinent in the case of bariatric surgery, which is a popular reason for Canadians engaging in medical tourism. While it can sometimes be difficult for Canadians to secure bariatric procedures within the Canadian health care system, traveling abroad for bariatric surgery is not recommended, as the potential side-effects of a botched procedure can be life threatening. Further, one has to consider that in order to decrease costs, reprocessing of single use instruments, or unapproved sterilization techniques are used, increasing the risk of catching resistant bacteria, fungus, and life threatening viruses. Lack of physician certification is common, with poor access to intensive care units, and advanced support care when a complication occurs.  Many patients are unable to get transferred back to Canada with the service of an air ambulance. The best course of action in this case is to consult a bariatric surgery specialist such as Dr. Michel Gagner in order to explore your options.

 

 

 

 

 

 

 

 

 

 

 

 

 

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New and Improved Methods in Laparoscopic Sleeve Gastrectomy Procedures

Recently, an article was published featuring Dr. Michel Gagner (program chair of ASMBS American Society for Metabolic and Bariatric Surgery) and Dr. Raul Rosenthal, director of the Bariatric and Metabolic Institute at the Cleveland Clinic in Florida. The two medical professionals were featured in an interview on the outcomes of the 2015 Sleeve Consensus, a conference on laparoscopic sleeve gastrectomy (LSG) procedures. New and improved methods for the surgery were discussed and also published in a paper. Here is a summary on their explanation of why most surgeons have adopted LSG as their main procedure since 2011.

Facts

According to Dr. Gagner, LSG is now the most common bariatric surgery procedure being performed at this time. Its popularity in comparison to the Roux-en-Y gastric bypass is due to the following reasons:

  • LSG is simpler, more efficient and has a lower chance of death
  • LSG has a lower chance of complications (50% less)
  • LSG has better preventative measures and reinforcements
  • As a result, there have been less bowel obstructions, gastrojejunal ulcers and cases of rapid gastric emptying (dumping) – a painful and uncomfortable syndrome that generally occurs after bypass surgery due to food moving into the small bowel too quickly.
  • There are also less serious micronutrient problems and cases of bone demineralization.
  • LSG can also be performed as a stand-alone procedure, on high risk patients, kidney and liver transplant patients, patients with metabolic syndrome, people with high body mass indexes (BMI) and associated conditions, patients with inflammatory bowel disease and older patients.

Why is it important to see a specialist vs. a general surgeon?

Dr. Gagner believes there is a gap between the knowledge of general surgeon groups and expert surgeons when it comes to LSG procedures. This is because:

  • Weight loss outcomes five years after surgery by an expert surgeon were significantly higher than general surgeon procedures.
  • There were less leakage rates.
  • Hiatal hernias (a hernia between the esophagus and stomach) can be corrected during LSG and need to be looked for by expert surgeons.
  • Hiatal hernias do not stop LSG procedures unless a severely incompetent sphincter is proven.
  • 80% of patients who experience GERD (Heartburn) \before surgery are cured, only 5% developed new reflux and need regular medications for it..
  • When LSG is performed as part of a two-stage procedure (which means less risky), insurance often covers both aspects of the procedure.

What can happen after an LSG procedure?

According to Dr. Rosenthal, gastroesophageal reflux disease (GERD) and Barrett’s esophagus, a severe form of GERD are still issues that are faced. Symptoms of GERD can occur especially after eating a big meal and the severity of these symptoms are dependent on a person’s BMI. It’s important to note however, that like leaks, this is something that will be focused on over the next decade. Therapeutic procedures are already being put into place and closely studied to remedy this issue.

Conclusions

Dr. Gagner believes that LSG should be seen as a primary procedure in treating obesity and the first step in treating type 2 diabetes in either non-obese or severely obese people. He believes that LSG procedures should override old notions of gastric bypass being the solution for diabetes as LSG has shown more promising outcomes.

 

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New Information on Type 2 Diabetes is Promising for Treatment Options

 A study was recently published in the journal Nature by the National Institute of Health outlining the complexity of Type 2 Diabetes as a disease. It went into greater detail on the issues this disease presents in order to uncover and identify more possible options for targeted treatments.

Brief Background

Type 2 Diabetes is a large health concern in the world, as over ten percent of the world’s population has this disease or is at risk for developing it. There are many risk factors for Type 2 Diabetes, but up to 90% of those who suffer from the disease are overweight or obese. This is due to the added pressure put on their body’s insulin, which regulates blood sugar levels.

Previous studies that explore the aspect of genetics in Diabetes risk have shown over 80 different areas in the human genome that are associated with Type 2 Diabetes. However, little has pointed to how these genetic changes (or variants) are distributed among different populations and how these variants lead to an increased risk for the disease.

Outcome of the Study

DNA sequencing of more than 120 000 people with ancestral origins across various continents in the world were coordinated by authors who ran the study in conjunction with the National Institute of Health and head of Molecular Genetics at the Human Genome Research Institute. They were able to find evidence that suggests that most of the genetic risk of type 2 Diabetes can be attributed to common and shared genetic variants rather than many rare variants unique to each individual.

They also found that a dozen genes in those with Type 2 Diabetes had altered structural changes in their genetic coding – suggesting that genes and proteins and directly involved in the development of the disease.

Conclusion

This is exciting news. Now that this has been confirmed, better drug treatments and new innovative and effective surgical procedures can be put in place to target at-risk patients and better plans-of-actions can be tailored to fit individual needs. Results also show that broad genetic profiles and environmental factors must be taken into consideration in order for this effort to be successful.

 

 

 

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The Link between Gut Biomes and Obesity

TED (Technology, Entertainment, Design) recently posted an article entitled “Can your biome make you fat?”, which features the work of Sandra Aamodt, a neuroscientist and author of the book Why Diets Make Us Fat. This book outlines the correlation between a person’s microbiome and their Body Mass Index (BMI). 

The human microbiome resides on or within a number of tissues in some of our major organs like mammary glands, lungs, biofluids, saliva and gastrointestinal tracts – to name just a few. The human gut – a large component of our gastrointestinal system –contains trillions of bacteria. We need these gut bacteria to digest our food and extract and convert the food into energy along with our digestive enzymes.

Aamodt’s book describes an experiment where researches produced “germ-free mice” without any gut bacteria that were raised in an insolation chamber. These germ-free mice ate 29% more food but had 42% less body fat than mice raised normally. When they were transplanted gut bacteria from a normal mouse, they started eating 27% less food, the same as a normal mouse while increasing their body fat by 60% in two weeks. However, when the germ-free mice were transplanted with gut bacteria from an obese mouse, they gained about twice as much weight as when the bacteria came from a normal mouse.

Gut Bacteria and Digestion

Bacteria types that commonly lead to weight gain and obesity are the ones that are especially good at extracting food energy. They are also good at breaking down complex carbohydrates. However, gut bacteria also have a profound impact on the absorption of nutrients – more than you would think!

Gut bacteria can have the following effects on our digestion:

  • Slow the movement of food – this allows for a complete extraction of nutrients
  • Increase the production of a particular enzyme – this moves glucose more efficiently from the small intestine into the blood
  • Suppress lipoprotein – this limits the ability of fat cells to take over fatty acids and triglycerides from the blood which allows for an increase in fat storage (this is particularly important as a regulator for obesity)
  • Reduce the use of fat for energy in the liver and muscles

The article and book allude to the idea that the lipoprotein suppression is what makes the mice gain 10% of their weight rather than 60%. The regulator of this pathway is blocked after the gut bacteria are transplanted.

The Main Issues with Treatment

Three main issues that stop this research from turning into a full treatment are:

  • They have not yet figured out how to apply this to help people lose weight. While there are possibilities with bacteria species that can help, it will be a long time before a microbiome therapy is born.
  • There’s too much of a discrepancy between the animal research and clinical therapy world – doctors can’t transplant bacteria into germ-free people the way they did with the mice in the study. Researchers will have to learn to work with the species already present in the gut.
  • Researchers are trying to find out what a desirable population of gut bacteria looks like. There are so many replications to be tried, from the ancestral microbiome to modern hunter-gatherers. The microbiome is also affected by adaptations to lifestyle, food sources and the type of bacteria in your body.

Microbiomes and Obesity

People with a less diverse set of gut bacteria are more likely to have weight issues and issues with their metabolism like metabolic syndrome (high blood pressure, blood sugar issues, cholesterol problems), all of which have adverse health effects.

The article states that based on their microbiome, researchers can predict whether a person will be of normal or abnormal weight with up to 90%, as opposed to 58% accuracy based on their genes. This is exciting news, and also sheds light on current issues regarding the overuse of antibiotics and how it can strip a person’s gut bacteria away to worsen or even cause weight gain problems.

This is but one in a series of emerging studies on microbiomes and their effect on our health, and their findings look promising for the future of obesity treatment. It is important to note that bariatric surgery is known to alter the microbiome of patients and may be one of the reasons why it is so successful for weight loss.

 

 

 

 

 

 

 

 

 

 

 

 

 

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Adult Obesity Trends in the USA

This year, the American Medical Association put out a study including data from the National Health and Nutritional Examination Survey (NHANES). The objective was to analyze obesity trends over the span of a decade (2005-2014), this time adjusting the data to include components of sex, age, race, smoking status and education.

The reason for the study: Previous NHANES data showed little change in obesity among adults in the United states from 1960-1980. However, in the second and third phase of their research (NHANES II and NHANES III) from 1976-1980, and 1988-1994, there was a significant increase in the prevalence of obesity. The reasons for the spike in numbers are unclear. This prompted the study to include other factors.

Ethnic Groups

In addition to the components mentioned above, pregnant women were excluded from analysis. Participants’ ages were also being grouped into categories of 20 to 39 years, 40 to 59 years, and 60 years and older.

Ethnicities were put into the follow categories: Hispanic white, non-Hispanic black, non-Hispanic Asian, Hispanic and other.

The non-Hispanic Asian category included predominantly individuals of Chinese, South Asian, Filipino, Vietnamese and Japanese descent.

Multi-racial participants were put into a separate category.

Smokers

  • Self-reported smoking status was categorized as never-smokers, former smokers and current smokers.
  • Never-smokers: Smoked less than 100 cigarettes in their lifetime
  • Former smokers: Smoked as many as 100 cigarettes but were not current smokers.
  • Current smokers: Those who reported that they smoke every day or some days.

Education

  • Less than a high school education
  • High school graduate
  • Post-secondary education

Findings and Conclusions

  • The prevalence of obesity in 2013-2014 among men differed significantly by race/Hispanic origin and by smoking status but not by age group or education.
  • The prevalence of obesity among non-Hispanic Asian men was significantly lower than among non-Hispanic white men.
  • Among women, the prevalence of obesity in 2013-2014 varied significantly by age group, race/ Hispanic origin, and education but not by smoking status.
  • The prevalence of class 3 obesity among men did not differ by age group, race/Hispanic origin, smoking status, or education.
  • The prevalence of class 3 obesity among women differed by age and race/Hispanic origin but not by smoking status or education.

The main findings show that there was an overall increased prevalence of obesity (a body mass index of 30), and class 3 obesity (a body mass index of 40).

The conclusions: The age-adjusted prevalence of obesity in 2013-2014 was 35.0% among men and 40.4% among women. The corresponding values for class 3 obesity were 5.5 % for men and 9.9% for women.

Between 2005 and 2014, the prevalence of overall and class 3 obesity showed significant increase for women while there were no significant increase trends for men.

Learn more about Dr. Michel Gagner and the bariatric surgeries offered at the clinic.

 

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Women with PCOS May Benefit from Weight Loss Treatments Before Conceiving

Women suffering from obesity or who are overweight often endure a range of health problems. It is well known that obesity can put you on the path to serious illness such as heart disease and stroke, blood pressure problems, Diabetes, certain kinds of cancers and various breathing problems that can affect normal sleep cycles.

What is PCOS?

PCOS or Polycystic Ovarian Syndrome is a condition where a woman’s ovaries continually produce benign cysts. Many women with PCOS are obese or overweight.

This can be caused by several factors that include genetics, but it is also linked to an underlying source: hormonal imbalances.

In women with PCOS, their ovaries make more androgens than normal – a hormone most often associated with males, but that females also make. These high levels of androgens affect the release of the eggs during ovulation and cause a variety of symptoms including:

  • Infertility problems
  • Ovarian cysts
  • Obesity
  • Irregular or prolonged heavy menstrual periods
  • Excessive facial and body hair
  • Insulin resistance in some women – a pre-diabetic condition in which the blood glucose levels are stabilized by creating higher amounts of insulin
  • Skin tags and dark patches
  • Anxiety or Depression
  • Pelvic Pain
  • Sleep Apnea

NIH Study

The National Institute of Health (NIH) recently published a study showing that obese women with PCOS who go through a significant weight loss treatment will better increase their chances of pregnancy: 187 obese and overweight women with PCOS were treated with Clomiphene, a drug that induces ovulation while another group of 142 women with PCOS began a weight loss program that was comprised of a combination of a lower caloric intake, exercise and anti-obesity medication – before they began the Clomiphene.

The women who did the weight loss program had a 62 % ovulation rate and a 25 % live birth rate over the women who were treated with the Clomiphene only, who had a 44.7 % ovulation rate and a birth rate of 10.2 %.

This finding could be significant in improving the health of women who suffer from PCOS and as a result have problems with fertility. Encouraging exercise and weight loss tactics in combination with medication will also help to alleviate the debilitating mental health effects of PCOS as well.

Learn more about our work at Clinique Michel Gagner by reading out FAQ.

 

 

 

 

 

 

 

 

 

 

 

 

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The Stigma of Obesity in the Health Care System

An article recently released in the Canadian Medical Association Journal (CMAJ) shows a disproportionate growth in the number of adults suffering from obesity (about 2 million people) in Canada. Obesity is a complex disorder often driven by genetics, but environmental, metabolic and behavioral factors can also come into play.

Canada’s Mentality

In Canada, health insurance coverage varies greatly, making bariatric surgery and related treatments difficult to access for many. A dangerous mentality is also present that continually leaves the availability of treatments severely restricted and unequal. The article states:

“Indeed, patients living with obesity continue to face widespread stigma and discrimination within the health care system. The “blame and shame” approach to managing obesity continues to find supporters despite evidence pointing to the ineffective and counterproductive effects of this strategy, which serves only to threaten health, generate health disparities and interfere with effective intervention efforts.”

The article goes on to suggest that that even with an increase in funding for bariatric surgery, there is a significant lack of infrastructure and trained health care professionals who are equipped to perform the surgeries and related tasks.

What Canada Needs to Do

The health care system in Canada needs to offer help on a primary level. Rather than having specialized centers, measures need to be put into place such as a triage system to assess those who are in the greatest need of bariatric surgery. This will ensure that those who need help the most will receive the right treatment first.

The Edmonton Obesity Staging System acts as a response to this issue and sets a good example that should be followed by the rest of Canada. It ranks the mental, medical and functional health of patients with obesity on a five-point scale.

This system:

Is a better way of sensing mortality in advance

Allows us to not ignore the situation – the immediate need for surgery will be prominent

Will reduce and limit weight gain to start rehabilitation

Establish chronic disease management practices such as patient education and self-management

Increase follow-up and support – an important aspect of any road to recovery

Integration of these issues into every level of health education – from physicians to allied health professionals

It’s time for Canada to see that obesity is on a similar spectrum as addiction – where there are significant physical and behavioral components involved beyond the idea of self-control. Rather than blame victims of obesity, we should seek to help them. Increasing infrastructure and providing adequate coverage in Canada will encourage people to get the proper help they need.

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New Research Suggests We Can Shut Off our Desire to Eat

 

Obesity is a widespread epidemic in North America: since the 1980s, the obesity rate has doubled. In Canada, 1 in 4 people are deemed clinically obese. The rise directly correlates with the intake of more refined sugars, processed foods and the growth of the fast food industry.

According to Medical Daily, obesity comes down to maintaining energy homeostasis – the balance between calorie intake and calorie burning. This is regulated by genes, proteins and enzymes in the body in addition to your diet and lifestyle. However, despite their best efforts, some people still struggle with obesity.

New research suggests that if you suppress the enzyme known as O-GLcNAc transferase (OGT), which regulates insulin and metabolism along with controlling food intake, this may create the ability to shut off the desire to eat.

The study involved injecting one group mice with a control virus, while another group was injected with a virus that inhibited their OGT function, which takes place in an area of the hypothalamus known as the paraventricular nucleus (PVN). The OGT-inhibiting mice ate double the amount of food the control mice ate. Their fat tissue was prevalent and it was only when their food intake was controlled that the OGT-mice were able to maintain a normal weight.

However, they found that when they stimulated OGT in mice afterward, the opposite effect came into place. Their food intake lowered as they craved less.

So what does this mean? This latest study, in addition to a previous study on genes and obesity may be grounds for developing a new drug that can target obesity at a basic biological level. Stimulating OGT in the body will be able to lower cravings and help a person’s impulse control. This will create the perfect situation to encourage better eating habits.

If you or a family member are suffering from obesity and you want help to start the process of making a healthy and significant change, considering reading about our bariatric surgery procedures at Clinique Michel Gagner. You can also get started by filling out our questionnaire.

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