In this episode, Tom Varghese, MD, FACS, is joined by Todd Heniford, MD, FACS, and Alexis Holland, MD, from the Carolinas Medical Center. They discuss the recent article by Drs Heniford and Holland, “Limited or Lasting: Is Preoperative Weight Loss as Part of Prehabilitation Maintained after Open Ventral Hernia Repair?” This study supports the implementation of preoperative optimization and weight loss before hernia surgery, which remains controversial. Long-term maintenance of preoperative weight loss before abdominal wall reconstruction is achievable and sustainable.
Disclosure Information: Drs Varghese and Holland have nothing to disclose. Dr Heniford is a surgical research grant recipient and receives speaking honoraria from WL Gore.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:03):
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Tom Varghese,and throughout the series, Dr Lillian
Erdahl and I will speak with recentlypublished authors about the motivation
behind their latest researchand the clinical implications
it has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants,
(00:26):
and not necessarilythat of the American College of Surgeons.
Hello, loyal listeners,
welcome to another podcastepisode of The Operative Word,
the official podcast of the Journalof the American College of Surgeons.
I'm your host, Tom Varghese,and I'm also the editor-in-chief
for the Journal of the American Collegeof Surgeons.
(00:47):
I'm joined todayby two superstars in the house
of surgery,Dr Todd Heniford and Dr Alexis Holland.
I'll let them introduce themselves.
Dr Heniford, go aheadand introduce yourself to our audience.
I am Todd Heniford.
I am the chief of GI and minimallyinvasive surgery, and I direct the hernia
center of the Carolinas Medical Centerin Charlotte, North Carolina.
(01:08):
Another word, I guess I should sayis that I'm actually going to be moving to
Endeavor Health, joiningMike Ujiki at Endeavor Health in Chicago
in about three months.
So my last day at CMCafter 26 years will be in about a month.
Well, congratulations, Dr Heniford.
And, since I trained,since I trained at northwestern.
I know Mike and Dr Talamonti in the groupvery well, so congratulations.
(01:31):
I love that, amazing position.You will do great.
And, any, financial disclosures are,
relevant to this current publication,Dr Heniford?
None that will pertain to this at all.
Thank you.
Perfect.
Dr Holland, go aheadand introduce yourself to the group. Yeah.
So I'm Alexis Holland.
I'm a third-year general surgery residentat Carolinas Medical Center.
I completed a year of researchin Dr Heniford's lab last year.
(01:55):
And I am also leavingon a whirlwind of events.
I am going
to transfer
to an integrated plastic surgeryprogram at Ohio State starting in July.
Well, congratulations, Dr Holland.
And, probably a big lossto Carolinas Medical Center.
But I'd say it's the nature of the beasthere in academic surgery.
But, thank you.
(02:15):
And, thank you for joining us on today'spodcast episode.
We are incredibly honoredto have the opportunity to discuss
your recently published article entitled,“Limited or Lasting: Is Preoperative
Weight Loss as Part of RehabilitationMaintained after Open
Ventral Hernia Repair?” Dr Alexis Hollandis the first author of this publication,
(02:37):
and Dr Todd Heniford is the senior authorfor this publication,
and this was published onlinein JACS in February 2025.
Thank you for the opportunityto engage on this, amazing discussion.
Dr Heniford, I will start with you.
From a 30,000ft view,
why is preoperative weight loss
(02:59):
critically important for hernia repairsin general?
Well, there are a few thingswe need to accomplish, and and often
when I'm talking to the residentsand talk to our fellows about how we
do the
best hernia repair possibleand not have a recurrence,
there are three thingsthat need to happen.
One is no wound complications,especially infection, that
(03:22):
if we have that,it increases their chance of failure
of the operationby more than three solved.
We'd need to get the fascia closed.
If we get the fascia closed,that really gives us a leg up.
If we don't, seven-fold long termincreased chance of hernia failure,
on our handsand and and it's also been documented by,
Mike Rosen, Mike Liang and others,almost exactly seven-fold.
(03:45):
And then the last thingis of picking an appropriate mesh.
And we like placing the meshin a preperitoneal
plane, rectorectus plane,or tore plane behind the wall if you can.
If you can get those three things done,
then you can expect a low failurerate at the operation.
High success rate. Yeah.
So how weight loss fits into thisfor every point of body mass index.
Greater than about 26, not 25,but it was 26.
(04:07):
In our data,you increase the chance of wound
complications,increase the chance of infection.
And then, also too,
in a paperwe published years ago that every point of
BMI essentially increasesintra-abdominal pressure.
And so often, a failure of a hernia repairis due to the pressure
in the abdominal wall,if you take someone with a body mass index
(04:31):
of greater than 35 and compare them tosomeone with a much more normal body mass
index of about 25, they have a 3 to 4times increased pressure in their abdomen
just with a standing cough,much less with anything else they do.
So you depressurize the hernia,the hernia repair,
you actually decreasethe complication rate.
And then also too,what we've demonstrated, even with
(04:53):
like 11 pounds of weight loss in patientsand looking at CT scans.
And Katie Schlosser,when she was in her lab years ago,
she demonstratedthat you significantly decrease the
the inter-abdominal volumeand our hernia volume.
So you that's a basic larger defectsallows you to get them closed, decreases
the pressure on the closure, decreasesthe chance of wound complications.
(05:15):
And also too, I'll just throw it outthere.
We're doctors, and helping our patientsto lose weight is a really good idea.
That's amazing.
Dr Heniford. And it was interesting.
I mean, you and I are old enough that,
when we were readingall these classic textbooks from, like, Dr
Nyhus and his studies from the 60sand 70s, you know,
I still remember as a resident,like one of the first principles
(05:37):
was before engagingin any type of hernia repair,
you should actively encourageyour patients to lose weight.
And, and so the other thingI loved about your project,
it it's almost like a throwbackto the fundamentals.
Like don't forget the fundamentals.
Let's, let's approach this, as well.
But, no, thank you for that answer.
Dr Holland, let me turn it to you.
How did you get interestedin this part of the project rather than.
(05:59):
And please don't say DrHeniford told you so.
And that'swhy I’m involved in the project.
It's like there's got to be.
There's gotta be something about thisproject that really appealed to you.
Yeah, I think we've actually doneseveral projects
this past yearthat are really all about prehabilitation.
I even toyed initiallywhen I was in medical school
with whether I wanted to domore of a primary care,
(06:20):
track, mostly just because I wantedto be able to follow patients long term.
And I think it's actually pretty coolthat,
abdominal wall surgeonsreally are quality of life doctors,
and being able to impact them
even after surgery, I think, is
what we're all called to do as doctors.
And so this projectand then a couple projects on diabetes
(06:41):
and smoking cessation to see if patientskept those goals, after surgery as well.
I think were all just pretty interesting.
That's amazing.
Well, let's dive into the article.
And then I'll start with, including,a really high recommendation for,
our listeners to go and take a lookat this phenomenal article.
So the study design, it was a prospective
(07:04):
single institution hernia database.
And Dr Heniford,you and the team have successfully said
that this is prospectively collecteddata, like, you know, large volume
data from a very, very busy,you know, center of excellence.
And it was queried specifically forpatients with a BMI greater than, 25 kg/m²
and who were requested to lose weight
and lost a minimum of 10 poundspreoperatively.
(07:26):
But I think that the key important thingfor this study was two time points.
That was the postoperative appointment,six months to a year.
And then of course, their,most recent documented weight,
we were really looking at long-termimpact.
Dr Holland, I'll start with you.
When you queried the database,you know what were, like,
(07:48):
how do you take a lookand make sure that the quality of the data
was accurate in terms ofwas there any sensitivity analysis,
or was this just one of those thingswhere you've done
so many different studiesthat the data itself was pretty reliable?
I would say we have trained
data analysts that help with all of thatkind of demographic information.
But me and my co-resident, Will Lorenz,
(08:11):
hand chart reviewed for all the weights.
So I feel pretty confident in those values
just because, we did that ourselves.
And then, Dr Henifordand actually our other attendants, our,
attendings are blinded to the database,which really help
deniability.
(08:32):
No, no, no, no, it's it's greatbecause I think that that's, you know,
one of the criticisms
people have lobbed against surgicalstudies in general, right, is like,
oh, it's biased and things like that.
And I think that that's amazing that,you know, people are actually blinded,
you know, during,you know, data acquisition,
and that you're taking a look at itafterwards, but, you know,
keep going, Dr Holland.
(08:53):
That that's the sensitivity analysis.
And then we had supervisionof our lab manager
who kept us all in line and made surethat everything was accurate.
And he would go back thereand double check, timed us.
Perfect. And, you know, do it.
Let's talk about the results.
So, the 256 included patients.
You know, it's it's fascinating.
You know, not surprisingly,you know, in conjunction
(09:16):
or reflection of the obesity epidemic,you know, 30% were diabetic,
you know, and almost 68% were ASAclass, 3 or 4.
And that at the initial consultation,the average weight loss,
this is again, this is priorto their prehabilitation program.
The initial BMI, was about 38.2,and then or
(09:38):
and at the time the surgery would had beendropped down to a BMI about 34.
And with the average weight loss,about, 26 pounds.
And then at the first postoperative timepoint, the BMI was 33.6.
So maintaining that thatand that they lost an additional
almost 2 pounds after surgery itself.
(09:58):
Dr Heniford, was that surprising to youthat, you know, they continue
to lose weight even after the surgery?
You know, actually, it really wasn't.
I mean, one of the thingsthe reasons we did the study is indeed
we had a lot of pushback, even though,
you know, for the reasonswe're today, that weight loss
is super importantin abdominal reconstruction, especially.
So when the body mass index of 38, 39, 40,
(10:21):
just for the reasons we described,and a lot of the pushback we get is
that people will say, all these peoplegain all their weight back.
I'm not going to do it. They're goingto gain their weight back anyway.
I mean, it's it really is a, it's a it'san easy exit out of trying to be a doctor.
And I don't mean to be too harsh in that,but but indeed, you know,
for all the reasons it's a good, good ideain abdominal reconstruction.
(10:44):
But then you say, well,they're just going to
gain their weight back,so I'm not going to do it.
But, you know,
some of the most important thingsthat that, Alexis showed in this paper
is that almost 50% of the people continueto lose weight after surgery
and on average, on average,lost another 19 pounds.
And so they on average lost 45 pounds.
(11:05):
They continue to keep this weight offfor years after their surgery.
And so yeah.
And since for all of the health reasons,you know, we can we can describe
and then they saywell you know in only 17 or
but almost 18%, almost 18% of themgain their weight back.
But I'll just say it the other way, only
17, 18% gained all their weight back.
(11:27):
And so the majority of these people, kepta large part of their weight off,
and almost 50% continued to lose weight.
And I think one of the things
that's super important about this is,is we talked to patients in the office.
We frequently, and I never want to do thismy whole career.
As I sit down, I talk about dieting.
I talk about how the ketogenic dietactually, genetically,
(11:48):
it kind of fits us as humans.
As, you know, for 70,000 yearsas hunter gatherers,
and actually probably longer than that.
And, and you know, and and the, yeah.
How much sugar is in our foodand how much sugar is in processed food
in the, in the grocery store, you know,80% of foods in the grocery store.
This process has added sugar.
And so, anyway,I never want to talk about that.
But one of the thingswe frequently heard from patients
(12:10):
is no one ever talked to me about thisbefore.
And, they made it part of their lifestyle.
And I thinkthat that's what's so important here.
Yeah, we're fixing hernias, but,you know, the the.
And when someone will lose on averagein this 50, almost 50% of patients,
40-45 pounds from the time they walkin the office to even years later,
(12:32):
we're really impacting their healthby a ton.
And I think that it's critically important
that you brought that outbecause, you know,
some people just assume that prescribinga GLP one agonist and that's it.
But that's not what you're doing.
Like that's complementaryto the comprehensive
prehabilitation programthat you're enrolling the patients in.
(12:55):
And is that a correct way of,you know, stating how you did the project?
That is that's correct.
And Alexis, at what percentageof these patients actually were on
or GLP-1s, 1.2% of patientstook GLP-1s prior to surgery.
That's it. So that's the important thing.
So it's not everybody was just prescribeda medication.
It's really the comprehensive enrollmentinto the program.
(13:18):
Correct, Dr Holland?
That, that's correct.
Our time frame was 2013 to 2023.
So I feel like it was right on the cusp ofwhen GLP-1s started becoming so popular.
It would be interesting to seewhat the weight loss would be,
even now that patients,so many patients are on them.
We also looked to make sure that,
(13:39):
you know, not a bunch of patientsare getting bariatric surgery.
Just under 10% of patientshad bariatric surgery, but they were,
they had bariatric surgerybefore their consultation with us.
So they still required weight loss.
And what Alexis meansand those people had their surgery.
That's bariatric surgeryyears before we saw them.
And so then
(13:59):
then they came in
stableand then and then continue to lose weight
that have been thathave been a bit of cheating in this study.
If we had included them. But. Right.
But you know, it will it'll timeit'll be interesting to
to think about like, you know,I think that GLP-1s can really help us
get patients to the operating roommore expeditiously
and, and, and help us, have lower
(14:22):
complication rates, lower recurrencerecurrence rates and all of that.
But the endpoint in this is, is thatif you don't teach people how to eat,
then perhaps this is not going to be lifesustaining.
I mean, teaching people how to eat,I think
is, has been truly, as a surgeon.
It this has been really quite rewarding.
(14:43):
Yeah.
And, you know, and I wanted to like, as,as we state that,
you know,I want to read the conclusion of the,
you know, the,
the abstract and essentially kindof summed up the discussion points to add
before we pivot to a coupleother questions I wanted to talk about.
And and again, full disclosure to theaudience, I'm unbelievably biased myself,
you know, you know,
helping with prehabilitationand preoptimization programs
(15:06):
such as Strong for Surgeryfor the American College of Surgeons.
So you can imagine when whatyou are my loyalties and my alliances lie.
But let me read the conclusion.
So the conclusion was,“Prehabilitation-induced weight loss
averaged 26 pounds.
With 3.5 years of follow up, patients
weighed an average of 24 poundsless than their initial consult weight.
(15:27):
Nearly half of the patientscontinued weight loss post-operatively,
and more than 70% maintainat least half of their weight loss,”
this is what Dr Heniford was saying,
“demonstrating longevityto the preoperative optimization.”
I guess when we think about itfrom a 30,000ft view,
I mean, obviously this study is the robustevidence-based support,
(15:48):
of these interactions that we havewhen the time of the preoperative
consultationand engaging into long term relationships
with our patients,really is the opportunity, correct?
I mean, that this is a transformativeopportunity where we can
it's not just talkingabout fixing one problem,
(16:08):
but it's really transforming the patient’sjourney.
So long term relationships, is that a way
of kind of capturingwhat the what the study is?
Dr Heniford?
Thank you, Tom.
And I will say I think you're right,but I also think that,
what we don't do as surgeonsas take advantage of our podium
(16:30):
when patients come in to see us, like,they don't go see their internist.
You know, once every,you know, once a quarter,
every other,you know, every six months, once a year.
And they they hear about weight lossand they hear about their diabetes
and their smoking and the like.
But when they come into a surgeon'soffice, it's a different experience.
I mean, maybe it's not a podium.
(16:50):
I mean, maybe it's a pulpit,because it's so meaningful
when a surgeon says, this is thisand many of these patients too,
as ventral hernia patients and surgicalventral hernia patients that had surgery
before, they recognize, you know,how difficult this is going to be.
They and often they've had complications.
They've had infectionsthat brought them in.
And they had operative complicationsthat caused their hernia.
(17:13):
And so they want to avoid those.
And I think that, you know,we are much more aware
and wonderful position of surgeonsto be able to influence our patients,
that perhaps internal medicine doctorsjust don't have the opportunity for.
Yeah, amazing.
And Dr Holland, as you areembarking on your, plastic surgery career,
(17:35):
what are some of the lessonsthat you've learned
from this project and othersthat you work with, Dr Heniford,
that you're going to be employingin your own practice in the future?
I would say similarlythat we just have a unique opportunity
to offer something to our patientsthat other types of doctors don't.
I think that it takes an extra 10,
15 minutes in your consultationwith your patients to really,
(17:58):
hammer home, ketogenic dietand talking about weight loss.
And I think just knowing that that extraamount of time is absolutely worth
it years down the line, that you can makesuch an impact on your patients that it's
it's a good reminder to all of usto really take the time
to get to know our patientsand counsel them on, all sorts of,
(18:18):
problems prior to their surgeries,whatever that may be.
Amazing.
And, Dr Heniford,I'll give you the final word.
If we were to say,
based on your experience,based on the studies you've done over
the years and based on this,
amazingarticle that's been published in JACS,
what would you say is the call to actionthat you would want to say that, you
(18:38):
you would love for all of us as surgeonsand surgeon leaders to embrace,
as we navigate the the journey at that.
I think that we know that betteroutcomes are driven by, you know,
weight loss in obese patientsor morbidly obese patients.
We know that we have bettersurgical outcomes in patients
who have elevated hemoglobin A1Cs,to drive those down.
(19:02):
And we also know that, helping patients
to stop smoking prior to surgerywill improve our outcomes.
And I think that like a study like thissaying that not only can we
impact them by fixing their herniaand that sort of thing,
but we can impact their liveswhen and in another study
that Alexis had doneand like looking at hemoglobin A1C, I mean
(19:24):
we have we track patients threeand another study over three
and a half years later after we'vegotten people’s hemoglobin A1C down
from an average of 8.5 to below 7.2,which actually their long term
hemoglobin A1C is a 6.9after three three and a half years.
If you think about it, that decreasesmicrovascular risk of, you know,
retinopathy and nephropathy and neuropathyby 35 to 40% in those patients.
(19:50):
And so, and then you combinelike weight loss and stopping smoking.
And you can take a middle age you knowwoman and I don't save lives anymore.
But you can it's like
people will drop their their BMIfrom from 40 to 28.
Stop smoking, a middle-aged woman canextend her life on average for 14 years.
(20:11):
Incredible. Well, I mean so yeah.
So, the long-term considerationof patient care, we just need to,
I would just say take advantageof the position of being a surgeon
and the trustthis patient puts in you for their lives
and and make it even more meaningful.
Stretch this out. Maybe. I don't know.
(20:32):
I mean, I don't
I don't save lives anymore, but maybe insome of the stuff, we actually do.
That's eloquently stated, well,
I yeah, Dr Heniford, to Dr Holland,thank you for the opportunity to,
engagewith us, for The Operative Word, the
the podcast for the Journalof the American College of Surgeons.
I highly recommend to our listenersto deep dive into this article,
(20:55):
but I'm also excited about,the opportunities ahead and really
looking forward to even more amazingstudies coming from your study group.
Thank you so much for joining us today.
Thank you for listening to
the Journal of the American Collegeof Surgeons Operative Word Podcast.
If you enjoyed today's episode,spread the word on social media
(21:16):
by using the hashtag #JACSOperativeWord.
Subscribe to The Operative Wordwherever podcasts are available,
or listen on the American Collegeof Surgeons website at FACS.org/podcast.
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Tom Varghese,and throughout the series, Dr Lillian
Erdahl and I will speak with recentlypublished authors about the motivation
behind their latest researchand the clinical implications
it has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants,
(00:26):
and not necessarilythat of the American College of Surgeons.
Hello, loyal listeners,
welcome to another podcastepisode of The Operative Word,
the official podcast of the Journalof the American College of Surgeons.
I'm your host, Tom Varghese,and I'm also the editor-in-chief
for the Journal of the American Collegeof Surgeons.
(00:47):
I'm joined todayby two superstars in the house
of surgery,Dr Todd Heniford and Dr Alexis Holland.
I'll let them introduce themselves.
Dr Heniford, go aheadand introduce yourself to our audience.
I am Todd Heniford.
I am the chief of GI and minimallyinvasive surgery, and I direct the hernia
center of the Carolinas Medical Centerin Charlotte, North Carolina.
(01:08):
Another word, I guess I should sayis that I'm actually going to be moving to
Endeavor Health, joiningMike Ujiki at Endeavor Health in Chicago
in about three months.
So my last day at CMCafter 26 years will be in about a month.
Well, congratulations, Dr Heniford.
And, since I trained,since I trained at northwestern.
I know Mike and Dr Talamonti in the groupvery well, so congratulations.
(01:31):
I love that, amazing position.You will do great.
And, any, financial disclosures are,
relevant to this current publication,Dr Heniford?
None that will pertain to this at all.
Thank you.
Perfect.
Dr Holland, go aheadand introduce yourself to the group. Yeah.
So I'm Alexis Holland.
I'm a third-year general surgery residentat Carolinas Medical Center.
I completed a year of researchin Dr Heniford's lab last year.
(01:55):
And I am also leavingon a whirlwind of events.
I am going
to transfer
to an integrated plastic surgeryprogram at Ohio State starting in July.
Well, congratulations, Dr Holland.
And, probably a big lossto Carolinas Medical Center.
But I'd say it's the nature of the beasthere in academic surgery.
But, thank you.
(02:15):
And, thank you for joining us on today'spodcast episode.
We are incredibly honoredto have the opportunity to discuss
your recently published article entitled,“Limited or Lasting: Is Preoperative
Weight Loss as Part of RehabilitationMaintained after Open
Ventral Hernia Repair?” Dr Alexis Hollandis the first author of this publication,
(02:37):
and Dr Todd Heniford is the senior authorfor this publication,
and this was published onlinein JACS in February 2025.
Thank you for the opportunityto engage on this, amazing discussion.
Dr Heniford, I will start with you.
From a 30,000ft view,
why is preoperative weight loss
(02:59):
critically important for hernia repairsin general?
Well, there are a few thingswe need to accomplish, and and often
when I'm talking to the residentsand talk to our fellows about how we
do the
best hernia repair possibleand not have a recurrence,
there are three thingsthat need to happen.
One is no wound complications,especially infection, that
(03:22):
if we have that,it increases their chance of failure
of the operationby more than three solved.
We'd need to get the fascia closed.
If we get the fascia closed,that really gives us a leg up.
If we don't, seven-fold long termincreased chance of hernia failure,
on our handsand and and it's also been documented by,
Mike Rosen, Mike Liang and others,almost exactly seven-fold.
(03:45):
And then the last thingis of picking an appropriate mesh.
And we like placing the meshin a preperitoneal
plane, rectorectus plane,or tore plane behind the wall if you can.
If you can get those three things done,
then you can expect a low failurerate at the operation.
High success rate. Yeah.
So how weight loss fits into thisfor every point of body mass index.
Greater than about 26, not 25,but it was 26.
(04:07):
In our data,you increase the chance of wound
complications,increase the chance of infection.
And then, also too,
in a paperwe published years ago that every point of
BMI essentially increasesintra-abdominal pressure.
And so often, a failure of a hernia repairis due to the pressure
in the abdominal wall,if you take someone with a body mass index
(04:31):
of greater than 35 and compare them tosomeone with a much more normal body mass
index of about 25, they have a 3 to 4times increased pressure in their abdomen
just with a standing cough,much less with anything else they do.
So you depressurize the hernia,the hernia repair,
you actually decreasethe complication rate.
And then also too,what we've demonstrated, even with
(04:53):
like 11 pounds of weight loss in patientsand looking at CT scans.
And Katie Schlosser,when she was in her lab years ago,
she demonstratedthat you significantly decrease the
the inter-abdominal volumeand our hernia volume.
So you that's a basic larger defectsallows you to get them closed, decreases
the pressure on the closure, decreasesthe chance of wound complications.
(05:15):
And also too, I'll just throw it outthere.
We're doctors, and helping our patientsto lose weight is a really good idea.
That's amazing.
Dr Heniford. And it was interesting.
I mean, you and I are old enough that,
when we were readingall these classic textbooks from, like, Dr
Nyhus and his studies from the 60sand 70s, you know,
I still remember as a resident,like one of the first principles
(05:37):
was before engagingin any type of hernia repair,
you should actively encourageyour patients to lose weight.
And, and so the other thingI loved about your project,
it it's almost like a throwbackto the fundamentals.
Like don't forget the fundamentals.
Let's, let's approach this, as well.
But, no, thank you for that answer.
Dr Holland, let me turn it to you.
How did you get interestedin this part of the project rather than.
(05:59):
And please don't say DrHeniford told you so.
And that'swhy I’m involved in the project.
It's like there's got to be.
There's gotta be something about thisproject that really appealed to you.
Yeah, I think we've actually doneseveral projects
this past yearthat are really all about prehabilitation.
I even toyed initiallywhen I was in medical school
with whether I wanted to domore of a primary care,
(06:20):
track, mostly just because I wantedto be able to follow patients long term.
And I think it's actually pretty coolthat,
abdominal wall surgeonsreally are quality of life doctors,
and being able to impact them
even after surgery, I think, is
what we're all called to do as doctors.
And so this projectand then a couple projects on diabetes
(06:41):
and smoking cessation to see if patientskept those goals, after surgery as well.
I think were all just pretty interesting.
That's amazing.
Well, let's dive into the article.
And then I'll start with, including,a really high recommendation for,
our listeners to go and take a lookat this phenomenal article.
So the study design, it was a prospective
(07:04):
single institution hernia database.
And Dr Heniford,you and the team have successfully said
that this is prospectively collecteddata, like, you know, large volume
data from a very, very busy,you know, center of excellence.
And it was queried specifically forpatients with a BMI greater than, 25 kg/m²
and who were requested to lose weight
and lost a minimum of 10 poundspreoperatively.
(07:26):
But I think that the key important thingfor this study was two time points.
That was the postoperative appointment,six months to a year.
And then of course, their,most recent documented weight,
we were really looking at long-termimpact.
Dr Holland, I'll start with you.
When you queried the database,you know what were, like,
(07:48):
how do you take a lookand make sure that the quality of the data
was accurate in terms ofwas there any sensitivity analysis,
or was this just one of those thingswhere you've done
so many different studiesthat the data itself was pretty reliable?
I would say we have trained
data analysts that help with all of thatkind of demographic information.
But me and my co-resident, Will Lorenz,
(08:11):
hand chart reviewed for all the weights.
So I feel pretty confident in those values
just because, we did that ourselves.
And then, Dr Henifordand actually our other attendants, our,
attendings are blinded to the database,which really help
deniability.
(08:32):
No, no, no, no, it's it's greatbecause I think that that's, you know,
one of the criticisms
people have lobbed against surgicalstudies in general, right, is like,
oh, it's biased and things like that.
And I think that that's amazing that,you know, people are actually blinded,
you know, during,you know, data acquisition,
and that you're taking a look at itafterwards, but, you know,
keep going, Dr Holland.
(08:53):
That that's the sensitivity analysis.
And then we had supervisionof our lab manager
who kept us all in line and made surethat everything was accurate.
And he would go back thereand double check, timed us.
Perfect. And, you know, do it.
Let's talk about the results.
So, the 256 included patients.
You know, it's it's fascinating.
You know, not surprisingly,you know, in conjunction
(09:16):
or reflection of the obesity epidemic,you know, 30% were diabetic,
you know, and almost 68% were ASAclass, 3 or 4.
And that at the initial consultation,the average weight loss,
this is again, this is priorto their prehabilitation program.
The initial BMI, was about 38.2,and then or
(09:38):
and at the time the surgery would had beendropped down to a BMI about 34.
And with the average weight loss,about, 26 pounds.
And then at the first postoperative timepoint, the BMI was 33.6.
So maintaining that thatand that they lost an additional
almost 2 pounds after surgery itself.
(09:58):
Dr Heniford, was that surprising to youthat, you know, they continue
to lose weight even after the surgery?
You know, actually, it really wasn't.
I mean, one of the thingsthe reasons we did the study is indeed
we had a lot of pushback, even though,
you know, for the reasonswe're today, that weight loss
is super importantin abdominal reconstruction, especially.
So when the body mass index of 38, 39, 40,
(10:21):
just for the reasons we described,and a lot of the pushback we get is
that people will say, all these peoplegain all their weight back.
I'm not going to do it. They're goingto gain their weight back anyway.
I mean, it's it really is a, it's a it'san easy exit out of trying to be a doctor.
And I don't mean to be too harsh in that,but but indeed, you know,
for all the reasons it's a good, good ideain abdominal reconstruction.
(10:44):
But then you say, well,they're just going to
gain their weight back,so I'm not going to do it.
But, you know,
some of the most important thingsthat that, Alexis showed in this paper
is that almost 50% of the people continueto lose weight after surgery
and on average, on average,lost another 19 pounds.
And so they on average lost 45 pounds.
(11:05):
They continue to keep this weight offfor years after their surgery.
And so yeah.
And since for all of the health reasons,you know, we can we can describe
and then they saywell you know in only 17 or
but almost 18%, almost 18% of themgain their weight back.
But I'll just say it the other way, only
17, 18% gained all their weight back.
(11:27):
And so the majority of these people, kepta large part of their weight off,
and almost 50% continued to lose weight.
And I think one of the things
that's super important about this is,is we talked to patients in the office.
We frequently, and I never want to do thismy whole career.
As I sit down, I talk about dieting.
I talk about how the ketogenic dietactually, genetically,
(11:48):
it kind of fits us as humans.
As, you know, for 70,000 yearsas hunter gatherers,
and actually probably longer than that.
And, and you know, and and the, yeah.
How much sugar is in our foodand how much sugar is in processed food
in the, in the grocery store, you know,80% of foods in the grocery store.
This process has added sugar.
And so, anyway,I never want to talk about that.
But one of the thingswe frequently heard from patients
(12:10):
is no one ever talked to me about thisbefore.
And, they made it part of their lifestyle.
And I thinkthat that's what's so important here.
Yeah, we're fixing hernias, but,you know, the the.
And when someone will lose on averagein this 50, almost 50% of patients,
40-45 pounds from the time they walkin the office to even years later,
(12:32):
we're really impacting their healthby a ton.
And I think that it's critically important
that you brought that outbecause, you know,
some people just assume that prescribinga GLP one agonist and that's it.
But that's not what you're doing.
Like that's complementaryto the comprehensive
prehabilitation programthat you're enrolling the patients in.
(12:55):
And is that a correct way of,you know, stating how you did the project?
That is that's correct.
And Alexis, at what percentageof these patients actually were on
or GLP-1s, 1.2% of patientstook GLP-1s prior to surgery.
That's it. So that's the important thing.
So it's not everybody was just prescribeda medication.
It's really the comprehensive enrollmentinto the program.
(13:18):
Correct, Dr Holland?
That, that's correct.
Our time frame was 2013 to 2023.
So I feel like it was right on the cusp ofwhen GLP-1s started becoming so popular.
It would be interesting to seewhat the weight loss would be,
even now that patients,so many patients are on them.
We also looked to make sure that,
(13:39):
you know, not a bunch of patientsare getting bariatric surgery.
Just under 10% of patientshad bariatric surgery, but they were,
they had bariatric surgerybefore their consultation with us.
So they still required weight loss.
And what Alexis meansand those people had their surgery.
That's bariatric surgeryyears before we saw them.
And so then
(13:59):
then they came in
stableand then and then continue to lose weight
that have been thathave been a bit of cheating in this study.
If we had included them. But. Right.
But you know, it will it'll timeit'll be interesting to
to think about like, you know,I think that GLP-1s can really help us
get patients to the operating roommore expeditiously
and, and, and help us, have lower
(14:22):
complication rates, lower recurrencerecurrence rates and all of that.
But the endpoint in this is, is thatif you don't teach people how to eat,
then perhaps this is not going to be lifesustaining.
I mean, teaching people how to eat,I think
is, has been truly, as a surgeon.
It this has been really quite rewarding.
(14:43):
Yeah.
And, you know, and I wanted to like, as,as we state that,
you know,I want to read the conclusion of the,
you know, the,
the abstract and essentially kindof summed up the discussion points to add
before we pivot to a coupleother questions I wanted to talk about.
And and again, full disclosure to theaudience, I'm unbelievably biased myself,
you know, you know,
helping with prehabilitationand preoptimization programs
(15:06):
such as Strong for Surgeryfor the American College of Surgeons.
So you can imagine when whatyou are my loyalties and my alliances lie.
But let me read the conclusion.
So the conclusion was,“Prehabilitation-induced weight loss
averaged 26 pounds.
With 3.5 years of follow up, patients
weighed an average of 24 poundsless than their initial consult weight.
(15:27):
Nearly half of the patientscontinued weight loss post-operatively,
and more than 70% maintainat least half of their weight loss,”
this is what Dr Heniford was saying,
“demonstrating longevityto the preoperative optimization.”
I guess when we think about itfrom a 30,000ft view,
I mean, obviously this study is the robustevidence-based support,
(15:48):
of these interactions that we havewhen the time of the preoperative
consultationand engaging into long term relationships
with our patients,really is the opportunity, correct?
I mean, that this is a transformativeopportunity where we can
it's not just talkingabout fixing one problem,
(16:08):
but it's really transforming the patient’sjourney.
So long term relationships, is that a way
of kind of capturingwhat the what the study is?
Dr Heniford?
Thank you, Tom.
And I will say I think you're right,but I also think that,
what we don't do as surgeonsas take advantage of our podium
(16:30):
when patients come in to see us, like,they don't go see their internist.
You know, once every,you know, once a quarter,
every other,you know, every six months, once a year.
And they they hear about weight lossand they hear about their diabetes
and their smoking and the like.
But when they come into a surgeon'soffice, it's a different experience.
I mean, maybe it's not a podium.
(16:50):
I mean, maybe it's a pulpit,because it's so meaningful
when a surgeon says, this is thisand many of these patients too,
as ventral hernia patients and surgicalventral hernia patients that had surgery
before, they recognize, you know,how difficult this is going to be.
They and often they've had complications.
They've had infectionsthat brought them in.
And they had operative complicationsthat caused their hernia.
(17:13):
And so they want to avoid those.
And I think that, you know,we are much more aware
and wonderful position of surgeonsto be able to influence our patients,
that perhaps internal medicine doctorsjust don't have the opportunity for.
Yeah, amazing.
And Dr Holland, as you areembarking on your, plastic surgery career,
(17:35):
what are some of the lessonsthat you've learned
from this project and othersthat you work with, Dr Heniford,
that you're going to be employingin your own practice in the future?
I would say similarlythat we just have a unique opportunity
to offer something to our patientsthat other types of doctors don't.
I think that it takes an extra 10,
15 minutes in your consultationwith your patients to really,
(17:58):
hammer home, ketogenic dietand talking about weight loss.
And I think just knowing that that extraamount of time is absolutely worth
it years down the line, that you can makesuch an impact on your patients that it's
it's a good reminder to all of usto really take the time
to get to know our patientsand counsel them on, all sorts of,
(18:18):
problems prior to their surgeries,whatever that may be.
Amazing.
And, Dr Heniford,I'll give you the final word.
If we were to say,
based on your experience,based on the studies you've done over
the years and based on this,
amazingarticle that's been published in JACS,
what would you say is the call to actionthat you would want to say that, you
(18:38):
you would love for all of us as surgeonsand surgeon leaders to embrace,
as we navigate the the journey at that.
I think that we know that betteroutcomes are driven by, you know,
weight loss in obese patientsor morbidly obese patients.
We know that we have bettersurgical outcomes in patients
who have elevated hemoglobin A1Cs,to drive those down.
(19:02):
And we also know that, helping patients
to stop smoking prior to surgerywill improve our outcomes.
And I think that like a study like thissaying that not only can we
impact them by fixing their herniaand that sort of thing,
but we can impact their liveswhen and in another study
that Alexis had doneand like looking at hemoglobin A1C, I mean
(19:24):
we have we track patients threeand another study over three
and a half years later after we'vegotten people’s hemoglobin A1C down
from an average of 8.5 to below 7.2,which actually their long term
hemoglobin A1C is a 6.9after three three and a half years.
If you think about it, that decreasesmicrovascular risk of, you know,
retinopathy and nephropathy and neuropathyby 35 to 40% in those patients.
(19:50):
And so, and then you combinelike weight loss and stopping smoking.
And you can take a middle age you knowwoman and I don't save lives anymore.
But you can it's like
people will drop their their BMIfrom from 40 to 28.
Stop smoking, a middle-aged woman canextend her life on average for 14 years.
(20:11):
Incredible. Well, I mean so yeah.
So, the long-term considerationof patient care, we just need to,
I would just say take advantageof the position of being a surgeon
and the trustthis patient puts in you for their lives
and and make it even more meaningful.
Stretch this out. Maybe. I don't know.
(20:32):
I mean, I don't
I don't save lives anymore, but maybe insome of the stuff, we actually do.
That's eloquently stated, well,
I yeah, Dr Heniford, to Dr Holland,thank you for the opportunity to,
engagewith us, for The Operative Word, the
the podcast for the Journalof the American College of Surgeons.
I highly recommend to our listenersto deep dive into this article,
(20:55):
but I'm also excited about,the opportunities ahead and really
looking forward to even more amazingstudies coming from your study group.
Thank you so much for joining us today.
Thank you for listening to
the Journal of the American Collegeof Surgeons Operative Word Podcast.
If you enjoyed today's episode,spread the word on social media
(21:16):
by using the hashtag #JACSOperativeWord.
Subscribe to The Operative Wordwherever podcasts are available,
or listen on the American Collegeof Surgeons website at FACS.org/podcast.
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