bariatric center -...

25Bariatric Center SpotlightBariatric Times • January 2016

WELCOME TO THE MOUNT SINAIHEALTH SYSTEM BARIATRICSURGERY COLLABORATIVE

Surgery for severe obesity hasbeen performed at The Mount SinaiHealth System hospitals for almost40 years. This experience providesthe foundation on which ourbariatric program was built. Ourhospitals have a long tradition ofquality and innovation in bariatricsurgery. We have been performinglaparoscopic, or minimally invasivesurgery for obesity since 1998. Oursurgeons have accomplished many“firsts” including the developmentof the technique for laparoscopicduodenal switch; moreover, the firstlaparoscopic sleeve gastrectomywas performed at Mount Sinai in2000.

In 2013, Mount Sinai merged itsthree bariatric centers to form oneprogram dedicated to the care ofpatients with obesity and metabolicdisease. The Mount Sinai HealthSystem has one of the largest andbusiest bariatric surgery programsin the United States. In 2015, over1,200 bariatric surgery cases wereperformed among The Mount SinaiHealth System Bariatric SurgeryCollaborative, which includes 1)The Mount Sinai Hospital, 2) MountSinai St. Luke’s, and 3) Mount SinaiBeth Israel. Our teams across thesystem consistently work togetherto make this collective program intoone of the most prolific bariatricsurgery sites in the country.

OUR LOCATIONSThe Mount Sinai Hospital.

Located just steps from CentralPark on the Upper East Side ofManhattan, The Mount SinaiHospital location is ideally located

to serve our patients.Mount Sinai St. Lukes. This

site is located near ColumbiaUniversity on the Upper West Sideand serves a large and diversepatient population.

Mount Sinai Beth Israel. OurMount Sinai Beth Israel location issituated at the “cross roads” of NewYork City near Union Square. It isthe anchor of the Mount SinaiHealth System in lower Manhattan.Mount Sinai Beth Israel is uniquelylocated, close to a transportationhub, and able to provide service toan area that includes Midtown andDowntown Manhattan andBrooklyn.

OUR STAFFWe have a full complement of

staff geared to providing care forpatients seeking weight losssurgery. Staffing throughout thethree sites are structured to meetrequirements for the Center ofExcellence Standards as defined bythe Metabolic and Bariatric SurgeryAccreditation and QualityImprovement Program (MBSAQIP),the nationwide accreditation andquality improvement program formetabolic and bariatric surgery,jointly sponsored by the AmericanCollege of Surgeons (ACS) and theAmerican Society for Metabolic andBariatric Surgery (ASMBS).

Our Surgeons. The MountSinai Hospital. Surgeons at thissite include the following: Drs.William Inabnet III, Daniel M.Herron, Linda P. Zhang, GustavoFernandez-Ranvier, Eric Edwards,Subhash U. Kini, Edward Chin,Scott Nguyen, and Brian Jacob.

Mount Sinai St. Lukes.Surgeons at this site include the

following: Drs. James McGinty,Ninan Koshy, John Harvey, KojiPark, and Scott Belsley.

Mount Sinai Beth Israel.Surgeons at this site include thefollowing: Drs. Paul Thodiyil, YuliaZak, Jerome Taylor, Burton Surick,Richard Friedman, Michael Leitman.Dr. Inabnet is available at bothMount Sinai Beth Israel and theMount Sinai Hospital.

Dr. Inabnet is Chairman of theDepartment of Surgery at MountSinai Beth Israel and providesoversight to the growth anddevelopment of The Mount SinaiHealth System Bariatric SurgeryCollaborative.

Dr. Thodiyil, as Director of theBariatric Surgery Program at MountSinai Beth Israel is responsible forexpanding its reach and

accessibility while developing theservice to a standard required forMBSAQIP accreditation.

Integrated Health. Our nursepractitioners work closely withpatients and surgeons in collectingclinical information and reviewinglaboratory results. They guide thepatient through the preoperativeprocess, coordinate their care withmultiple specialties, triage andrespond to clinical enquiries andparticipate in patient education.They are involved in the patient’slifelong follow up, includingparticipation in patient supportgroups.

Our registered dietitiansundertake a patient’s initialnutrition evaluation, determines ifthe patient is an appropriatecandidate for surgery from a

BARIATRIC CENTERSpotlight

THE MOUNT SINAI HEALTHSYSTEM BARIATRICSURGERY COLLABORATIVE:One Healthcare System, Three Distinct Sitesby WILLIAM B. INABNET III, MD, FACS

Bariatric Times. 2016;13(1):25–29.

This column is dedicated to featuring accredited bariatric centers around the world, with a focus on their facilities, staff, statistics, processes, technology, and patient care.

Full staff of the Mount Sinai Health System Bariatric Surgery Collaborative.

The Mount Sinai Health System Bariatric Surgery Collaborative is one healthcaresystem with three distinct sites: Mount Sinai Hospital,Mount Sinai St. Luke’s, andMount Sinai Beth Israel.

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26 Bariatric Center Spotlight Bariatric Times • January 2016

nutritional standpoint, instructsthe patient on diet and exercisefor weight loss and educates thepatient about post-operative dietand supplement. They organizeand conduct a preoperative classfor patients in the month prior tosurgery, reviewing preoperativeand postoperative diet andsupplement guidelines. Inconjunction with the surgeons, thedietitians review pre- andpostoperative nutritionallaboratory results and recommendchanges to the patient’ssupplement regimen asappropriate. They provide acontinuity of care, seeing patientsduring their hospital stay andthereafter in their life-long followup through office visits andsupport group meetings.

During the patient’s hospitalstay, they are cared for by thesame team of registered nurseswho are experienced in lookingafter patients undergoing weightloss surgery. They are sensitive tothe needs of the patients and areeducated on their postoperativecare, including awareness of earlysigns of complications.

The financial counselors workwith patients from their earliestcontact, clarifying the insuranceprocess, determining eligibilityand coverage for bariatric surgery.They further inform the patientabout fees for which they may beresponsible. The counselorsrequest prior authorization for theplanned procedure andcommunicate the outcome to thepatient and the hospital.

Our office receptionistswelcome patients during theiroffice visits and work onregistering patients into theelectronic medical records (EMR)system. They triage phone callsand patient enquiries.

The clinical staff is supportedby administrative assistants whoschedule patient visits andsurgeries. They field phone callsand act as liaison between patientand the various clinical staff.

The practice supervisorsorchestrate the smooth operationof the program, ensuring that theentire team works in concert tocreate a positive experience forthe patient.

Bariatric surgery coordinatorsand clinical reviewers work closelywith the program director inobtaining and maintainingMBSAQIP accreditation. Thecoordinators assist in programdevelopment and in maintainingcompliance, with a focus onpatient safety and qualityimprovement. The clinicalreviewer extracts patient datafrom the medical records andreports them to MBSAQIP.

OUR FACILITIESAll office and hospital waiting

areas are equipped with bariatricsize chairs, blood pressure cuffs,weight scales, and wheel chairs.The bathrooms are wheel chairaccessible, and the toilets aremounted on the ground. The examrooms are large and the examtables are specific to bariatric sizepatients.

The design of the clinical spaceat each site ensures adequatesized doorways to accommodatebariatric wheelchairs and walkers.The waiting rooms have widecorridors to allow for bariatricpatients and their families.

PROCEDURE STATISTICS ANDPATIENT DEMOGRAPHICS

The current annual operativevolume of the program exceeds1,200 cases; with continuedprojected growth and the additionof the MSBI campus to theprogram, the annual case volumeshould increase to 1,500 cases,making The Mount Sinai HealthSystem Bariatric SurgeryCollaborative one of the largest inthe country. This strategic growthinitiative will transform ourcollective programs into one of themost prolific bariatric surgerysites in the country.

ACHIEVING ACCREDITATIONDESIGNATION

Having just launched theprogram in May 2015, Mount SinaiBeth Israel is in the process ofapplying for accreditation and hasalready exceeded the minimumcase threshold of 50 stapled casesto be designated atComprehensive Center. Withappropriate staffing in place,institutional support, andexcellent patient outcomes todate, we do not anticipate anydifficulty in completing theprocess of accreditation as aComprehensive Center.

Dr. Inabnet is a member of theMBSAQIP Standards Committee,which created and wrote thenational standards for theMBSAQIP program. Furthermore,Dr. Inabnet was Co-Chair of theASMBS Quality and StandardsCommittee, which oversaw theinitial transition from the Centerof Excellence to MBSAQIP.MBSAQIP promotes quality inbariatric surgery by following alllaparoscopic or open primaryprocedures in sleeve gastrectomy,gastric bypass, biliopancreaticdiversion with duodenal switch,and adjustable gastric banding, aswell as all revisions to previousbariatric procedures. An additionalfeature of MBSAQIP is theconferral of recognition tobariatric surgery centers that meetor exceed a set of rigorous peer-

The bariatric surgeons at The Mount Sinai Hospital. Pictured from left to right: Daniel M. Herron, MD, FACS; Melissa Chang, MD; Eric Edwards, MD, FACS; Linda P.Zhang, MD, FACS; Subhash U. Kini, MD, FRCS; Edward Chin, MD, FACS; GustavoFernandez-Ranvier, MD; Scott Nguyen, MD, FACS. Not pictured: Brian Jacob, MD, FACS

The bariatric team at Mount Sinai Beth Israel. Pictured from left to right: LeslieRosenbruch, RD; Jerome Taylor, MD; Richard Friedman, MD, FACS; PayalSharma, NP; Paul Thodiyil, MD, FRCS, FACS; William B. Inabnet III, MD, FACS;Burton Surick, MD, FACS, and Yulia Zak, MD

The bariatric team at Mount Sinai St. Luke’s. Pictured from left to right:Victoria Drake, ANP; Betsy Rojas; Rebecca Sabreen, RD; John Harvey, MD,MRCS; Dina Corjuc; Koji Park, MD; Toni Colarusso, RD; Ashish Padnani, MD;James McGinty, MD, FACS; Tania Castillo ; Ninan Koshy, MD; Mala Ayyakad;Kelly Suarez. Not pictured: Scott Belsley, MD, FACS

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reviewed quality standards. Thisvoluntary review is conducted atmore than 400 participating sitesacross North America and Canada.

Since 2011, The Mount SinaiHospital has been recognized as aan MBSAQIP Accredited Center—Comprehensive. The Department ofSurgery at The Mount SinaiHospital has earned this distinctionby demonstrating use of a high levelof resources in bariatric surgery inorder to accommodate all patients,including those with complex healthhistories or specific needs.

Under MBSAQIP, the divisionaims to meet or exceed thefollowing quality improvementbenchmarks for bariatric surgery: 1)An overall 30-day morbidity rateless than the national average; 2)rate of readmissions below thenational average; and 3) a 30-dayre-operation rate of zero for leak,gastrointestinal perforation, andintestinal obstruction.

Mount Sinai St. Luke’s has beenan accredited center since 2008.The most recent semi-annual reportdemonstrates that they are in thetop decimal for morbidity andmortality rates. Furthermore,Mount Sinai St. Luke’s reports someof the lowest complication rates forgastric bypass surgery, whichaccounts for 50 percent of theirsurgical case volume.

PATIENT ASSESSMENTMedical assistants measure

patients’ accurate height andweight. to calculate body massindex (BMI). Patients with BMIs of40kg/m2 or more are consideredappropriate candidates for bariatricsurgery. Patients with BMIsbetween 35 and 40kg/m2 requireadditional diagnostic testing todetermine if they are appropriatecandidates. Patients with type 2diabetes mellitus (T2DM) with BMIsbetween 30 and 35kg/m2 also meetcriteria for weight loss surgery.Patients undergo cardiac andpulmonary testing to determinefitness for surgery; psychologicalevaluation to assess for untreatedpsychiatric disorders or substanceabuse and evaluate capacity tounderstand and followpostoperative instructions. Theyalso have a number of blood tests tolook for any underlying endocrinecauses of obesity.

PATIENT ADHERENCE ANDFOLLOW UP

We schedule follow up visits atone week postoperatuve and thenat three, six, nine, 12, and 18months and thereafter annually.The administrative assistants placecalls to patients 24 hours prior totheir scheduled appointments toimprove adherence to follow up.Follow up data are tracked in theMBSAQIP database that allows

generation and reporting of follow-up metrics. Patients that fail toattend three consecutiveappointments are sent a returnreceipt letter with a follow upreminder.

Patients in the New Yorkmetropolitan area tend to movewith some frequency, so it is oftenchallenging to follow our patientswhen they change their homeaddress and contact phonenumbers. Rising out-of-pocketexpenditure through insurance

deductables and co-insurance mayalso contribute to poor follow up.

The preoperative patient goesthrough a clinical pathway designedto optimize surgery and ensureadherence with National Institute ofHealth (NIH) criteria for weightloss surgery. The records aredocumented in an electronicmedical records system that iscompliant with the HealthInformation Technology forEconomic and Clinical Health(HITECH) Act. The data generated

at external physician offices anddiagnostic facilities are received viasecure fax lines and HIPAA-compliant encrypted e-mail. Oncethe checklist of preoperative testingis complete, the patient is seen fora final preoperative visit. At thistime the patients receive a reviewof the procedure, answers to anyquestions they might have prior totheir procedure, and a date forsurgery. Two weeks prior tosurgery, patients are started on alow-calorie (800 kcal) diet. He or


28 Bariatric Center Spotlight Bariatric Times • January 2016

she is then sent for anesthesia pre-surgical testing.

After scheduling a surgical date,our patients are brought back to theoffice for a half day during whichthey undergo a pre-operative classthat reviews the surgerytechniques, what to expect in thehospital and immediatepostoperative period, diet andexercise guidelines, multivitaminand protein supplementation, andsigns and symptoms ofcomplications.

OUR EQUIPMENT AND NEWTECHNOLOGIES

Our EMR system (Epic, Verona,Wisconsin) has allowed us to handlethe large volume of clinicalcommunications in a much moremanageable fashion. It facilitatestwo-way communication through asecure and HIPAA-compliantpathway. Patients who do not haveinternet access at home areencouraged to use the computer wekeep in our waiting room to accesstheir electronic records. At presentEpic is available only at The MountSinai Hospital; Epic integration atthe other sites will occur in 2016,thereby, further facilitatingcollaboration.

Recently, we have embraced thecapabilities of mobile technology.Using an app called Epic Haiku,providers can access our EMRsystem. Through this app, we havesecure access to clinic schedules,hospital patient lists, healthsummaries, test results, and notes.Although the app is available onmultiple mobile devices, some findthat devices with larger screensmake for better viewing of labresults, imaging results, andinpatient vital signs anddocumentation. It is important tonote that all of our sites havecampus-wide secure WiFi networkprovided by our hospital system,which make it possible for us toutilize the benefits of mobiletechnology.

We have experimented with somemobile-based billing applications,but have been somewhat hinderedby the high costs of these packages.We continue to research newequipment and technologies thatmay be beneficial to our practices.

SCHEDULING/INVENTORYOnce patients have completed

their preparation process,administrative assistants schedulethem for surgery. Our current EMRsystem allows us to access apatient’s chart and print necessarypaperwork for schedulingprocedures.

The practice supervisors keeptrack of the inventory for thepractice and all necessary suppliesare ordered by our nurse directors.We make sure that we have all

necessary supplies ready for use. Operating Room tables all meet

specifications to accommodate thelargest bariatric patients. Longinstruments, scopes, and staplersare available as needed.

MANAGED CAREManaged care has not affected

our ability to provide excellentservice to our patients; however,rising out-of-pocket expenditurethrough insurance deductables andco-insurance may contribute topoor patient adherence topostoperative follow up.

COST AND EFFICIENCYIn order for us to help our

patients through the processefficiently, we participate withalmost all major insurance plans.Most of our patients have a verylimited out-of-pocket budget andmost of the time it’s based on theirin-network benefits.

We do not ask our patients tocontribute to any “program fees,”although we ask for a smallpayment for nutritionist visits,which are generally not covered byinsurance. These fees can bewaived for special situations.

PATIENT AND STAFF TRAININGAcross The Mount Sinai Health

System, an obesity care map hasbeen implemented; one criteria ofthis plan is that two attendinganesthesiologists be present for theinduction of anesthesia in patientswith a BMI greater than 40kg/m2.

Our anesthesiologists minimizepostoperative somnolence so thatpatients can move themselves fromthe operating room table to thegurney. We believe patientmobilization is important to earlyrecovery and encourage patients toambulate starting the night ofsurgery. In patients with impairedmobility, we use standard transferaids such as air transfer systemsand low-friction slide boards in theoperating room.

EMERGING TRENDSThe single most enabling

technology for both patients andproviders has been the near-ubiquitous emergence of cellphones and high-speed networkaccess. Patients use their phones toimprove communication with ourteam at every level.

Laparoscopic instrumentationhas remained fairly stable over thepast few years. We would like to seeimproved display technology in theform of 4K cameras and monitors.Robotic surgery is gainingincreasing ground in surgery of thegastro-intestinal tract and we wouldlike to cautiously explore itsapplication in bariatric surgery.

Our continually growing translational research team indiabetes/obesity clinical research works closely with thebariatrc surgery team at The Mount Sinai Hospital on

multiple levels. Our researchers are supported by the NationalInstitutes of Health (NIH), American Diabetes Association(ADA), and other pharmaceutical companies in diabetes andobesity. We have experts in type 2 diabetes mellitus (T2DM)and obesity clinical trials (Drs. Jeanine Albu, Ryan Walker,Carol Levy, and Daniel Donovan) and the genomics of obesity(Dr. Ruth Loos). Dr. Scott Friedman leads a research groupdedicated to studying fatty liver and nonalcoholicsteatohepatitis (NASH). Mount Sinai also conducts research onthe microbiome and its role in obesity and related diseases(Drs. Jeremiah Faith and Jose Clemente).

As the need for diabetes/obesity clinical research continuesto grow, so do our teams and initiatives. We are currentlyrecruiting additional researchers in adipocyte biology and otherareas of fuel metabolism, diabetes, and obesity research. Ourfuel metabolism research group includes Drs. ChristophBuettner, Derek LeRoith, Emily Gallagher, and Sarah Stanley.The broad expertise of clinical investigators provide anessential compliment to the remarkable work achieved by theMount Sinai Health System Bariatric Surgery Collaborative.

In addition to these areas, the internationally recognizedpancreatic beta cell research group at Mount Sinai (Drs. AdolfoGarcia-Ocana, Nathalie Fiaschi-Taesch, Donald Scott, RupangiVasavada, and Andrew Stewart) perform basic and translationalresearch focused on human pancreatic beta cell regenerationand expansion for people with types 1 and 2 diabetes, asexemplified by recent publications in Nature Medicine, CellMetabolism, and Diabetes.1–4 In collaboration with Dr. Inabnet’steam, the Stewart group has developed what we believe is thelargest repository of human insulinomas. Insulinomas aretypically small benign tumors that contain the “genomic recipe”for gentle and effective human beta cell expansion. TheStewart-Inabnet team seeks to identify these molecular targetsfor drug discovery by exploring the genomics andtranscriptomics of these unusual, benign insulin-secretingtumors.

For more information on translational research, visithttp://icahn.mssm.edu/research/institutes/diabetes-obesity-and-metabolism-institute

MOUNT SINAI: FOCUS ONTRANSLATIONALRESEARCH INDIABETES/OBESITY

by ANDREW STEWART, MDDirector, Diabetes Obesity and Metabolism Institute, Professor Medicine, Endocrinology, Diabetes and Bone Disease

1. Wang P, Alvarez-Perez JC, Felsenfeld DP, et al. A high-throughput chemical screenreveals that harmine-mediated inhibition of DYRK1A increases human pancreaticbeta cell replication. Nat Med. 2015;21(4):383–388. Epub 2015 Mar 9.2. Stewart AF, Hussain MA, García-Ocaña A, et al. Human β-cell proliferation andintracellular signaling: part 3. Diabetes. 2015;64(6):1872–1885.3. Bernal-Mizrachi E, Kulkarni RN, Scott DK, et al. Human β-cell proliferation andintracellular signaling part 2: still driving in the dark without a road map. Diabetes.2014;63(3):819–831. 4. Kulkarni RN, Mizrachi EB, Ocana AG, Stewart AF. Human β-cell proliferation andintracellular signaling: driving in the dark without a road map. Diabetes.2012;61(9):2205–2213.Epub 2012 Jun 29.



AN INTERESTING CASEDiagnosed with liver failure

and three months to live,patient undergoes life savingbariatric surgery. Ms. R was a 48-year-old mother, resident of PuertoRico, and owner of a cateringbusiness received news during aroutine doctor appointment that herliver was failing. She weighed 309lbs, struggled with T2DM for 12years, and was receiving 180 unitsof insulin a day. Struck with panicand fear that she would die fromliver failure, she reached out forhelp. Her sister who lived in NewYork, relayed that the family’sprimary physician recommendedThe Mount Sinai Hospital.

Ms. R flew out to New York foran appointment on December 20th.She met with the transplant teamwho told her that, at this point,there was nothing they could do.They said she would not survive thesurgery at her current weight andthat her only option was to trybariatric surgery first. The teamreferred her to Dr. Subhash Kini,Associate Professor of Surgery andMinimally Invasive Bariatric surgeonat The Mount Sinai Hospital. Dr.Kini explained this was a very highrisk surgery. He also mentioned thatif gastric varices were found withinthe abdomen upon the operation, hewould not be able to continue withsurgery. He advised that Ms. Rimmediately start exercising and

begin a very strict diet to lose asmuch weight as possible beforesurgery, which was tentativelyscheduled for the following April.Ms. R, with support from her family,made the effort to change herlifestyle and lost 40 lbs.

Finally, the day arrived. After thefour-hour surgery was completed,Dr. Kini said everything went well.Ms. R was walking that same dayand was released on PostoperativeDay 1. During surgery, Dr. Kininoticed that Ms. R’s liver appearedseriously diseased. One month later,she met with the transplant teamagain. They said that her lifestylechanges and surgery helped toimprove her liver functions.

Ms. R continues to follow up withboth the bariatric surgery andtransplant teams. Due to hertransformation, doctors predict thatshe may not need to have a livertransplant. Ms. R reports that she ishappy with her life transformationand notes that little tasks no longertire her, such as crossing her legsand walking up inclines. She is alsoproud to say that she can now shopanywhere for clothes that fit.

Ms. R expressed sinceregratitude to the bariatric team atThe Mount Sinai Hospital, especiallyto Dr. Kini who she calls hersuperhero. “A superhero’s missionis to save people, and that’s exactlywhat he did. He saved me,” shesaid.

A UNIQUE FACILITYThe Bariatric Surgery program at

the Mount Sinai Health System hasseveral transformational initiatives.First, our goal is to expand bariatricsurgery services across the System.We continue to standardize clinicalpathways and recruit new faculty toaccommodate the strategicexpansion.

The Mount Sinai Health SystemBariatric Surgery Collaborativeconvenes a system-wide meetingevery six months to discussoutcomes, refine clinical pathways,vet research protocols and enhancecollegiality. Each site hosts themeeting on a rotating basis.Monthly meetings occur on aregular basis at each site.

To learn more about The MountSinai Health System BariatricSurgery Collaborative, visit our newwebsitehttp://weightloss.surgerymountsinai.org/.

FUNDING: No funding was provided.

DISCLOSURES: The author reports noconflicts of interest relevant to the contentof this article.

AUTHOR AFFILIATIONS: William B.Inabnet III, MD, FACS, is Chairman,Department of Surgery, Mount Sinai BethIsrael, Eugene W Friedman Professor ofSurgery, Icahn School of Medicine MountSinai, New York, New York.

ADDRESS FORCORRESPONDENCE:Dr. William B. Inabnet III, E-mail:[email protected]

The single most enabling technology for both patients and providers has been the near-

ubiquitous emergence of cell phones and high-speed network access. Patients use theirphones to improve communication with our team at every level.

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