Programs & Services

Adam Goldstein, D.O., F.A.C.S.

Dr. Goldstein Explains Detailed Process for Gastric Band Surgery

It doesn't cost anything other than a couple hours of listening time, but it could be the first step toward bariatric surgery and the chance for a new way of life for the morbidly obese.

A free monthly lecture by Adam Goldstein, D.O., F.A.C.S., is a prerequisite before he will see a new patient in the office. That's because the lecture is also a screening tool for those considering the surgery. The talk and Q&A session are so candid, so detailed in explanation, that some attendees realize right then that they are not qualified candidates and there is no reason to schedule an appointment to see Dr. Goldstein in the office. The lecture also provides those interested in weight-loss surgery with everything they would need to know to make an informed decision about whether the surgery is right for them.

A member of the bariatric surgery team at Our Lady of Lourdes Medical Center, Dr. Goldstein said the lecture is just the first step in the process that can lead to successful surgery and substantial weight loss. That process includes:

The Lecture

Dr. Goldstein meets all new bariatric patients at an evening group lecture during which he speaks for about an hour and then answers questions from the group. "I don't just talk about the Lap-Band®, which is what I do, but give them all the surgical options and the pros and cons of each" said Dr. Goldstein.

"I tell them the reality—this surgery is not going to solve their problem all by itself, it's their commitment that makes it work, that solves the problem. But if they are not willing to make the lifestyle changes it requires, then they should not have the surgery."

The Criteria

Those who attend the lecture are fulfilling the very first requirement—listening to his initial explanations and his criteria for patients.

He will only operate on patients whose Body Mass Index is between 35 and 55 and whose weight is no more than 350 pounds. (The BMI is an index, using height and weight calculations, to estimate health risk related to weight. The upper limit normal BMI is 25. See a BMI calculator here. He explained his reasons for these criteria:

"The data show when your BMI goes over 55 the risks associated with the surgery start to rise dramatically. The reason I limit the weight to 350 pounds is that when I later do gastric band adjustments using fluoroscopy, the fluoroscopy table has a limit of 350 pounds. I will not accept a patient I can not care for appropriately afterwards.

"If a patient weighs more than 350 pounds, or has a BMI greater than 55, we will have the patient use the nutritionists available to them to assist them in getting their weight down prior to the surgery. I have been successful in operating on patients who initially came to the office weighing over 400 pounds and were able to lose a significant amount of weight preoperatively."

"What percentage of my patients get rejected at the time of their appointment? It's actually quite low, because in the lecture I give I go through everything they need to meet the criteria. So if they calculate their own BMI and if it is 33, for example, then they know there is no point is making an appointment."

Evaluation and "To-Do" List

Those who attend the evaluation and want an appointment are given a questionnaire—eight pages of detailed questions—to fill out so the physician has plenty of data before he sees them for a physical evaluation.

If he believes an individual is a candidate for gastric band surgery, Dr. Goldstein gives the person a "to do" list that they must complete in order to undergo the operation.

"It's an itemized checklist of all of things they need to accomplish to prepare their surgery and to make sure there is no reason why they can't have it, said the surgeon. "Each person's checklist is different, some may need cardiologic evaluation some may not, some may need pulmonary, some may not."

"Keep in mind that part of that checklist everyone gets is a psychological evaluation. It is critical they be evaluated by a psychological professional to make sure there is no eating disorder, to make sure they know what they are getting themselves into, and that their mind is stable.

"I send them out with the checklist. When the evaluations and data come back I assess them and if there are no red flags in the pre-op workup, they come in to discuss consent for surgery and ask their questions. Then they are scheduled for the operation."

Pre-Surgery Education and Weight Reduction

Dr. Goldstein said each patient must be evaluated and educated by a nutritionist to understand this core truth:

Gastric band surgery does not change the patient's life. The patient changes his or her life. Surgery merely is a tool that must be used properly to make the desired change.

"The nutritionist teaches the patient: OK here is what your dietary habits have been, and here is what they're going to be after the operation. If you don't feel you can make those changes, then don't have the operation because it's not just about having a band put in you, you have to make those changes."

And that is why Dr. Goldstein requires patients to shed 10 percent of their excess body weight before the operation.

"If you are 100 pounds overweight I ask you to lose 10 pounds, 200 pounds overweight, lose 20 pounds," he said. "If you are 100 pounds overweight and start making the right food choices, the weight comes off right away with no trouble. It proves to me they get it. It's not just about having an operation, it's about changing their life and I help them do that.

"It's not necessarily a diet and I'm not asking them to run a mile a day, just make better choices, not eating donuts for breakfast, pizza for lunch. They change the way they eat and they immediately see results. I give them as much time as they need, but if it does not come off, I postpone the operation and talk with them."

Some surgeons put patients on a liquid-only diet just prior to the procedure, but Dr. Goldstein does not think it appropriate.

"Think about what you're doing, you're putting a patient who is not excessively healthy as it is, on an operating table, in a nutritionally depleted state. You're going to starve them a week before the surgery?"

"They are weakened after surgery and the healing process requires calories, protein, energy, so why deplete them of energy? I think that creates an increased risk of healing problems, wound infections and so forth. I am putting a foreign device in their bodies and do not want to put them at an increased risk of infection."

Bariatric Surgery at Our Lady of Lourdes Medical Center

(See a detailed description of the gastric band and procedure here.)

Dr. Goldstein aims to make the laparoscopic band procedure a same-day operation, but that depends on what turns up in pre-op evaluations. "If the patient does not have sleep apnea, does not have diabetes and they are not a BMI of over 55, then potentially they can be done as an outpatient procedure," he said.

In reality, only some 30 percent of the patients go home that day and the rest stay overnight.

"The screening process can find sleep apnea, diabetes or other conditions and so they become an overnight stay. I want to make sure their blood sugar is adequately controlled post-op and that they don't have a sleep apnea episode on the night after surgery."

Dr. Goldstein, who operates at Our Lady of Lourdes Medical Center, noted that OLOMC has earned a Center of Excellence designation from the American Society of Metabolic and Bariatric Surgery.

"They have the physical plant and pieces in place to care for a bariatric patient, someone who is 100, 200, 300 pounds overweight. They have all the specialists available—cardiologists, internists, (critical care) intensivists—so that if a complication should arise they have ability to care for the patient. Plus they have the pieces in place for support post operatively. All those components make it a Center of Excellence."

Post-Op Follow Up

Bariatric patients are monitored closely in the weeks following their procedure. Dr. Goldstein puts them on a special staged diet—from liquid to solid food within a five week period—to ease their way into a new way of eating. Once they are on a solid food diet, they will be instructed to eat only four to six ounces at a sitting.

"The nutritionist will educate them so they balance their intake," said the physician. "They are told to make a priority of protein and nutrients, then carbohydrates and then fats, in that order. But we all need a certain amount of fat which provide essential fatty acids that we can not manufacture ourselves.

"I also have them take vitamins because it is difficult to get everything you need in the typical American meal."

Once the patients have the surgery, is it guaranteed that they will lose the desired amount of weight?

Not without support, Dr. Goldstein said.

"Support is critical. Some patients may not really be hungry after a small meal, but mentally they think it is not providing the comfort they sensed from overeating. They need post-op support so they can hear from other patients who have gone through this.

"If they feel they are not making the right choices they need to talk with the nutritionist again. That help is here for them. The psychologist is here for them, a psychologist trained in bariatrics to reinforce the goal of the therapy, to control what they think about food so they see it as source of fuel to run their daily activity.

"If you don't have these modalities of support - psychological, nutritional, other patients -- then the chance of you succeeding is low."

Like all surgeons, Dr. Goldstein sees his surgical patients several weeks after surgery to check their physical progress. But his gastric band patients also require periodic checks to make sure the band is inflated at the right level and in the proper position. (See details in this article about the band.)

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