Q&A with Dr. Mark Fusco
If you’ve ever been on a diet you know the challenges in controlling your weight. Government research indicates that about two-thirds of adults in the United States are overweight, with half of those people considered obese. Obesity translates into unhealthy side effects, including diabetes, heart disease and a 10 to 50 percent higher risk of death from all causes compared with healthy weight individuals. As the obesity problem has grown in the U.S., so has the number of people turning to weight loss or bariatric surgery, with two popular choices being Gastric Bypass and the Lap-Band® procedure.
Dr. Fusco is a graduate of The Johns Hopkins University and New York Medical College and received residency training in general surgery from Keesler Air Force Base Medical Center. After fellowship training in critical care from Vanderbilt University, Dr. Fusco began a practice in general surgery with an emphasis in laparoscopic surgery in 1994.
Gastric Bypass has been around the longest and is the best known. During this in-patient operation, surgeons make the stomach smaller, which results in an early feeling of fullness and allows food to bypass part of the small intestine so fewer calories are absorbed. Patients leave the hospital within two to four days and the weight loss can be dramatic within the first year. It’s a very difficult operation to reverse.
In 2001, the FDA approved the Lap-Band as a reversible, surgical weight loss option that’s primarily done on an outpatient basis. Using minimally invasive laparoscopic surgery through tiny incisions, the surgeon places a band around the stomach that’s then tightened to make the stomach smaller. Tiny meals then “hang up” in the smaller stomach pouch long enough for the person to feel full before food passes normally through the intact digestive system. Weight loss results are similar to gastric bypass, but may be slower, with the optimum weight reached in the second year following the procedure.
Because the Lap-Band is relatively new on the scene, SCM&HL talked with Melbourne surgeon Mark Fusco, MD about what’s become one of the fastest growing weight loss surgeries. He’s a board-certified general surgeon with Melbourne Internal Medical Associates (MIMA) who specializes in laparoscopic surgical techniques. In 2003, he began performing Lap-Band procedures as the medical director of the Lifeshape Advanced Bariatrics Center of Florida, a cooperative venture with Melbourne Same-Day Surgery Center. Since then Dr. Fusco has performed close to 400 Lap-Band cases and works with the product’s manufacturer, Allergan, to train other surgeons in the Lap-Band operation.
SCM&HL: When would someone be a candidate for weight loss surgery?
Dr. Fusco: This is for people who have serious medical weight issues — not for cosmetic weight problems. Surgery is an option for people who have a Body Mass Index over 35 and associated medical problems or over 40 without medical problems. (BMI is a standard index of weight adjusted for an individual’s height.) That roughly correlates to someone who, depending on height, is 60 to 100 pounds overweight. You have five times the risk of heart disease and diabetes if you’re obese at age 50. Since we’re doing this for health, what we’re trying to achieve is enough weight loss so we get health benefits. My patients have all tried a tremendous number of things to get their weight under control without success, and a lot of times there’s an event that may finally spark them into action, such as a new diagnosis of diabetes.
SCM&HL: Why do the majority of your patients choose the Lap-Band over other options?
Dr. Fusco: My patients gravitate toward the Lap-Band because of the increased safety involved. It’s done on an outpatient basis so they can go home and return to work quicker. It’s a tool to help with hunger control. The thing that distinguishes Lapband over the gastric bypass is that the intestines are not divided or re-routed, which decreases the risk of there being leaks or nutritional malabsorption issues. The long-term benefit of Lap-Band over traditional bypass is the band is adjustable so it’s just tight enough that people have some hang up of food in their pouch to help the hunger control, but not so tight that they can’t eat good solid, healthy food. That adjustability is really a key element because it gives you the ability to customize it for every patient and change it as needed. If the patients have any significant issues that require them to have a little better nutrition, for example if they get pregnant, or have to have another kind of surgery, or if they get cancer and need to have chemotherapy — the fact that the band is adjustable gives us the ability to deflate it and allow them to take in more nutrition if they should need it, which is a very nice safety valve.
SCM&HL: How do you adjust it after surgery?
Dr. Fusco: It’s strictly an office procedure. The band includes a saline-filled balloon that adjusts how tight it is. We sew an access port to the very bottom part of the belly and it’s under the skin, so all you see is a little bump. We put in or remove saline fluid using a very fine needle with no need for anesthesia. The first few weeks after surgery they’re on a healing diet and at week three they have a follow up appointment to advance their diet to a more normalized diet. Then at week six we start the process of adjusting the band to get the right tightness. We have an open door policy about making adjustments.
SCM&HL: Explain a little more about the post surgical diet and the weight loss people can expect.
Dr. Fusco: Patients will eat two to four, four-ounce meals a day, which is roughly the same size meals as what someone can eat after gastric bypass. If the band is properly adjusted then that amount of food makes them feel satisfied. If the band is too loose, that four ounces drops out of the pouch too quickly and they have increased hunger. In addition to a properly adjusted band, what foods you eat also play a role. You can imagine that if you drink four ounces of soup that leaves the pouch almost immediately, you don’t get as good of hunger control as if you had three ounces of chicken and one ounce of broccoli.
Because health risks start to go up with a BMI above 27 or 28, we set out as a goal to get a patient’s BMI below 30. A good percentage of excess weight loss is considered to be 50 percent. It has been my experience that the average percent excess weight loss after three years is 53 percent, which has proved to be very satisfactory. If someone’s initial BMI is 50 they have a five times normal risk of premature death. So even if you get the BMI down to 40, which some might say is not a great weight loss, you’ve gotten down to two and a half times the risk of premature death using outpatient surgery that had minimal risk.
SCM&HL: This involves a major lifestyle change so how do you support Lap-Band candidates before and after surgery?
Dr. Fusco: When they contact our office, they’ll be sent an introductory packet and asked to attend a two to three hour patient information seminar where we talk about obesity and the different treatment options. We usually have from two to four of our past patients talk about why they had surgery, what it was like, how their life has changed afterwards and then we answer questions they may have and discuss insurance issues. Those people who want to go forward are required to have a detailed consultation with our dietitian, an evaluation with our psychologist or, if they’re already working with a mental health professional, an evaluation with their own, plus a pre-operative evaluation with their primary care doctor. They meet with our after-care coordinator who is in control of all the support care issues afterwards. They get a pre-operative anthesthesia evaluation and only after all that is done do they come see me. We want to be sure they’re prepared to make every aspect of the changes they need to make. Exercise is very important for maintenance of weight loss, so we emphasize that in our pre and post-operative teaching.
Post surgery, once we’re into the band adjustment process, we have the patient come for a three-month follow up dietitian appointment, we ask them to come in for monthly weight checks and see me yearly after surgery. We have monthly, in-person support groups. Last July, after discovering the majority of our patients use the Internet, we also started something we call the Weight Goal Portal. It’s their Internet home page which interfaces with our weight loss database so it tells them what their last weight was, how much they’ve lost, when they’re due for their next weigh in, or it will flash that they’re overdue.
SCM&HL: What about the costs? Are insurance companies covering weight loss surgery?
Dr. Fusco: There was a backlash in the beginning primarily due to the complications and costs some people experienced from gastric bypass surgery. There’s powerful medical data that shows the benefits. When we started, insurance coverage was minimal, but now little by little, more and more insurance companies are seeing the benefits and seeing better outcomes and with the Lap-Band there are fewer complications so fewer insurance companies are excluding coverage for bariatric surgery. Medicare now approves the Lap-Band and weight loss surgery in general when it’s medically indicated.
Since many patients still may be self-funded we’ve developed a package price for the Lap-Band of $16,750, which includes all routine follow up care for the first year. (Editor’s note: That compares to a $26,000 average cost for Gastric Bypass which requires a two to four-day hospital stay.)
SCM&HL: What about the risks?
Dr. Fusco: There are the traditional risks of any surgery, including the risk of bleeding, infection and blood clots. Then risks for the band itself are that it could slip out of place and not work properly so we’d have to do another surgery. That happens about four percent of the time. The little access port that goes underneath the skin could have problems and if that happens that would take another small operation to change out the port.
The 30-day mortality rate for having Lap-Band surgery, in other words the risk of being dead from any cause in the first 30 days after surgery, is about 1 in 2000 people, which is about one-tenth of the most commonly quoted number for gastric bypass. So it’s about 10 times safer than gastric bypass. But I always stress in the pre-surgical seminar that we have to take even the small risk seriously when making the decision. If you look at people’s chance of being around five years after the surgery, they had an 89 percent reduction in mortality compared to people the same weight and age who did not have weight loss surgery. The most dangerous thing someone could do is stay morbidly obese.
FOR MORE INFORMATION on the Lap-Band and LifeShape Advanced Bariatrics Center of Florida call 321.728.7553 or visit www.LifeShape.net
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