Establishing a community bariatric surgery center at Northern Dutchess Hospital and pursuing recognition as a Comprehensive Bariatric Center at Putnam Hospital Center, Health Quest is building on its commitment to providing high-quality, conveniently located bariatric care to patients from throughout the region. The work of Brian Richard Binetti, MD, FACS, bariatric surgeon at Health Quest Medical Practice and Medical Director of the Bariatric Program at Northern Dutchess Hospital, stands on the strong foundation of Health Quest’s bariatric surgery program at Putnam Hospital Center. Anthony Maffei*, MD, FACS, Medical Director of the Bariatric Surgery Program at Putnam Hospital Center and Assistant Professor of Surgery at New York Medical College, has guided the program’s development since 2011.
A patient is prepped before surgery by the surgical team (left to right): Brian Richard Binetti, MD, FACS, bariatric surgeon at Health Quest Medical Practice and Medical Director of the Bariatric Program at Northern Dutchess Hospital; Michael Moses, MD, Director of Anesthesia; Roberto Dos Reis, Clinical Coordinator of Surgical Physician Assistant Services; and Christy Latimer, Registered Nurse.
Health Quest’s current bariatric surgery program services the Mid-Hudson Valley from Poughkeepsie south to Putnam County. By adding bariatric surgery services at Northern Dutchess Hospital, Health Quest expands the service farther north. Educational seminars offered at all three hospitals in the Health Quest system and online webinars now give patients the opportunity to stay in their communities or even stay in the comfort of their own homes to learn about Health Quest’s bariatric surgery program.
Dr. Binetti welcomes the opportunity to bring both primary and revisional bariatric surgery options to Northern Dutchess Hospital.
“I was able to come to Health Quest and start this program because of their commitment to developing a high-quality program devoted to creating good short- and long-term outcomes,” Dr. Binetti says. “Health Quest has provided the resources we need for success. They take pride in offering specialized care in smaller hospitals and communities and in serving patients who might otherwise have to travel to large cities to receive first-rate medical treatment.”
Close Ties to the Community
With his background teaching and operating at a tertiary medical center, but also with roots in Northern Dutchess Hospital, Dr. Binetti is uniquely positioned to create an excellent program for the people of Rhinebeck and the surrounding area.
He was a fellow in minimally invasive and robotic surgery at Albany Medical Center, where he was also a clinical instructor in surgery. In addition, he served Northern Dutchess Hospital as a staff general surgeon from 2009 through 2011, and he lives in the community.
Dr. Binetti began performing bariatric surgery in Albany in 2008, though he was interested in offering the procedure in Rhinebeck and maintained privileges at Northern Dutchess Hospital.
“When Health Quest was looking to start a bariatric program here, I was looking to be close to home,” he says. “The timing was ideal.”
Work at a tertiary referral center brought Dr. Binetti training and experience that now benefit patients locally. As part of a high-volume center where he was an assistant professor and co-director of a bariatric fellowship, he handled a variety of challenging cases. He is also experienced in the latest laparoscopic and robotic approaches to bariatric surgery. Recent advances have expanded the number of minimally invasive procedures that can be performed, Dr. Binetti says. For example, sleeve gastrectomy is now a brisk, one-hour procedure followed by a single night in the hospital.
Northern Dutchess Hospital bariatric team (left to right): Mae Antonio, Bariatric Surgery Coordinator; Dr. Binetti; and Roufia Payman, Certified Dietitian Nutritionist
“The surgery involves four to five small incisions,” he explains. “We then mobilize the greater curve of the stomach leading up to the left crus of the diaphragm. Once the stomach is completely mobilized, we use a special sizing device called a bougie and a stapling device to create a stomach with a capacity of approximately 2 to 3 ounces. This effectively removes close to 90 percent of the stomach.”
The procedure is extremely safe, with a complication rate of less than 1 percent in the 30 days after surgery, according to the American Society for Metabolic and Bariatric Surgery (ASMBS).
Revision Surgeries, Performed Locally
Northern Dutchess Hospital will perform revisional as well as primary metabolic procedures, thanks to Dr. Binetti’s highly specialized training.
Endoscopic revision involves entering through the throat to revise a gastric bypass, Dr. Binetti explains.
“We approach through the mouth endoscopically and tighten the bypass without using incisions,” he says. “This is a less invasive technique we can offer patients in place of what was previously a fairly complex surgery.”
At Northern Dutchess Hospital, Dr. Binetti will also perform surgeries to convert a gastric band to other types of weight-loss options. In addition, he will accept referrals of patients who need a sleeve gastrectomy converted into a bypass procedure or who need a revision of a bypass surgery. Even these revision procedures can now be performed laparoscopically, he points out.
“A further advantage to patients is that I retain my privileges at a tertiary referral center,” he says. “I can identify patients who might benefit from the capabilities of a larger medical center and can perform the procedures there, rather than refer them to a different program or surgeon. That promotes continuity of care.”
A Well-planned Journey
Patient selection, preparation and follow-up are now highly defined for maximum success. National standards of care are promulgated by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Patients are selected in accordance with the capabilities of the center, and they must receive full preoperative education. Detailed psychological, behavioral and medical profiles feed into an algorithm, clearing each patient for surgery, according to the MBSAQIP’s Resources for Optimal Care of the Metabolic and Bariatric Surgery Patient 2016. Patients must demonstrate they understand and are compliant with the instruction they have received as well.
Mae Antonio, Bariatric Surgery Coordinator at Northern Dutchess Hospital, shares a real-life experience with a patient.
“We are single-mindedly focused on helping patients achieve their goals,” Dr. Binetti says. “All patients see me, and I assess each one. They work closely with the dietitian and nutritionist to develop healthy eating habits, learning to recognize their caloric intake based on portion size and to make healthy food choices. In that respect, they are working toward weight loss prior to surgery — in fact, they are required to lose 5 percent of their body weight before their procedure.”
The required weight-loss condition fosters patients’ commitment to overcoming the challenges involved in losing weight and maintaining weight loss, Dr. Binetti says.
“Everyone will lose weight after surgery,” he says. “The key is maintaining the weight loss for two, five, 10 or 15 years, and beyond. We screen patients at a psychological level, looking for eating disorders that can sabotage success.”
The preoperative journey involves two support group meetings, education about the variety of surgeries available, and getting up to date on routine cancer screenings, as well as metabolic evaluations. Preoperative education is available by viewing an online webinar or attending a seminar.
“It’s definitely a long-term commitment,” Dr. Binetti says. “It’s important for patients to understand that surgery is only one aspect of their weight loss. The emotional, psychological and other aspects of losing weight are also extremely important in the long run.”
However, patients do not undertake those challenges alone. Postoperative protocols ensure patients receive ongoing medical and social support.
Certified Dietitian Nutritionist Roufia Payman helps to guide patients toward success both pre- and postoperatively.
“When patients are assigned a day for surgery, they immediately have two years of follow-up visits scheduled,” Dr. Binetti says. “At the early visits, we are evaluating whether they can drink enough liquids to stay hydrated. We check for signs of postoperative complications. We do look for weight loss, but we are also looking for a healthy transition to being able to eat foods of all kinds, just in smaller portions and appropriately chosen based on their nutritional value.”
The step-by-step patient journey provides twofold benefits: Patients can make the most of their surgery, receiving medical and social support along the way, while no stone is left unturned to ensure outcomes are optimized.
“At this point, we have been able to streamline the surgery so it is becoming as safe as having your gallbladder removed,” Dr. Binetti says. “A lot of that has to do with the surgical prerequisites and testing. Those improvements are born out of the rigorous requirements that programs must meet to become MBSAQIP Accredited Centers.”
Even before Dr. Binetti arrived, he notes, Northern Dutchess Hospital aspired to that designation. The hospital performed its latest remodel with an eye on MBSAQIP compliance: Corridors were widened, toilets were made more secure, and spacious beds were brought in, for example.
“It is important to us to become part of that community of excellence that is fostered at MBSAQIP Accredited Centers,” Dr. Binetti says. “We will use the guidance that has been developed over so many years to make our center successful.”
Regularly scheduled, professionally supervised support groups make up an important part of the MBSAQIP standards of care. Multiple studies have confirmed benefits for patients who regularly attend support groups: They lose larger percentages of body weight than non-attendees, and they are more likely to follow guidelines for postoperative diet and exercise.
Dr. Binetti visits a postsurgical patient during rounds.
At Northern Dutchess Hospital, the Bariatric Surgery Coordinator oversees support groups in collaboration with our certified dietitian/nutritionist and ensures the bariatric program meets American College of Surgeons (ACS) standards.
“She is a former bariatric surgery patient,” Dr. Binetti says, “and she is excited to use her experience and knowledge to help other patients succeed in the program and meet their goals.”
One-on-one relationships are also essential, and Dr. Binetti looks forward to forging those ties at Northern Dutchess Hospital.
“The size of our program and hospital allows us to be more intimately involved with our patients’ pre- and postoperative care,” he says, noting that partnering with primary care physicians in the community will also facilitate patient selection and enable more effective follow-up care. “Here, the personal aspect will never be overlooked.”
Fostering Greater Access
The most important development in bariatric surgery at Putnam Hospital Center in recent years, Dr. Maffei says, has been the shift to performing sleeve gastrectomies as the most frequent procedure. However, another promising change, he notes, is that bariatric surgery is increasingly recognized as beneficial to patients who have a lower BMI than was previously the standard cutoff for this procedure.
Northern Dutchess Hospital bariatric surgical team (left to right), Registered Nurse Christy Latimer, Dr. Binetti, Dr. Moses and Roberto Dos Reis
Dr. Maffei and his colleagues want to provide bariatric surgery for patients who have a BMI of 30 or lower, meaning conditions such as high blood pressure, diabetes, obstructive sleep apnea, high blood cholesterol and other problems associated with obesity could be resolved before those diseases have progressed as far. He cites a study published in The New England Journal of Medicine in 2014 analyzing bariatric surgery’s effectiveness in managing diabetes in people who are mildly or moderately overweight before surgery. In that study, more than 1,000 diabetic patients with BMIs between 25 and 35 underwent bariatric surgery. The surgery proved to be as safe for the lower-BMI patients — those with a BMI of less than 30 — as for the others. The study’s lead author told the ASMBS, “The risk-benefit profile that has emerged for bariatric surgery in people with Type 2 diabetes and low BMI is very favorable and should be considered as a treatment option in carefully selected patients.”
Dr. Maffei says expanded guidelines would benefit many people, and that withholding surgery from appropriate patients can be harmful.
“It’s been shown that bariatric surgery, in combination with medical therapy, diet and exercise, is significantly more effective than medical care alone at putting patients’ comorbidities into remission,” he says. “Why should we discriminate against patients who are 60 pounds overweight versus those who are 80 pounds overweight, if the benefits from surgery are so profound?”
Dr. Maffei proposes to start with employees and their families on Health Quest’s insurance plan, providing a benefit to a large swath of the community, he notes, because Health Quest is a major Hudson Valley employer.
“We’d like to adopt those criteria and offer bariatric surgery to lower-BMI patients with certain comorbidities at Health Quest,” he says. “It’s a very interesting plan that’s in the works now. It would allow us to open the opportunity for surgery to a much larger patient population. This would set us apart from other bariatric programs in the surrounding area.”
Rigorous Quest for Recognition
In keeping with its record of excellent outcomes, Putnam Hospital Center is completing an application to be recognized as a Comprehensive Bariatric Center by the ACS and ASMBS. Supported by an experienced nursing staff, counselors, anesthesiologists and other professionals, the program offers high-level, wrap-around care. Each patient receives individual nursing and recovers in a private room. Comprehensive services include nutritional counseling, psychiatric and cardiac clearance, support groups, and extensive follow-up care.
Putnam Hospital Center Bariatric team (left to right): Alexandra Nichols, Registered Dietitian and Certified Dietitian Nutritionist, Gretchen Montazella, Bariatric Surgery Coordinator, and Anthony Maffei, MD, Bariatric Surgeon on the Putnam Hospital Medical Staff and Medical Director of the Bariatric Surgery program at Putnam Hospital Center.
Laparoscopic bariatric surgery being performed at Putnam Hospital Center
Dr. Maffei is confident the program’s rigorous standards and outstanding results will support the recognition.
“We are most proud of our outcomes,” he says. “Our complication rate is well below the national average. We have performed more than 600 cases without a leak or a patient death, and we take great pride in that record.”
Putnam Hospital Center has strived to offer optimal opportunity for safe and effective outcomes. Many of those event-free surgeries were complex revision procedures, such as conversion of band or sleeve to bypass, etc., Dr. Maffei adds. Others involved patients whose BMI was as high as 70. Putnam Hospital Center’s careful planning helps avert complications in these patient groups.
“The required presurgical weight loss makes the operation easier for us and safer for the patient,” Dr. Maffei says. “Specifically, it shrinks the liver, leading to a more convenient anatomy upon which to operate.”
Extremely obese patients undergo the same nutritional counseling as others do, though more extensively. Like other patients, they receive cardiac and psychological workups. Additionally, they are evaluated by an anesthesiologist before surgery.
They are challenged to make a strong mental commitment, demonstrated by measurable changes in behavior and physiology.
“We’ve had patients lose as much as 100 pounds before surgery, just working with our dietitians and exercising,” Dr. Maffei says. “This is a testament to how comprehensive our program is.”
Commitment to Collaboration
Rooted in the towns it serves, Health Quest hospitals reach out in numerous ways to connect with families where they get routine medical care and build lasting relationships with primary care providers.
“We require all patients who desire bariatric surgery to get a letter of medical necessity from their primary care physician stating they would benefit from the surgery,” Dr. Maffei points out. “We then stay in close contact with the physician before and after the surgery. We make sure patients have their vitamin levels checked and get the primary care physician on board with tapering down their medications.”
“The bariatric program at Northern Dutchess Hospital is poised to provide individualized, attentive, expert care to our patients.”
— Brian Richard Binetti, MD, FACS, bariatric surgeon at Health Quest Medical Practice and Medical Director of the Bariatric Program at Northern Dutchess Hospital
Putnam Hospital Center bariatric surgical team
More than 80 percent of bariatric surgery patients experience some degree of improvement or remission from diabetes or other conditions comorbid with obesity following their surgery, he notes, making it imperative to adjust medications immediately after the procedure and to continue monitoring each chronic health condition and its treatment carefully. Patients who had high blood pressure or high blood sugar before surgery may not realize how dramatically their medications will need to be adjusted, he says, and some may experience low blood pressure or low sugar before they get their medication levels right.
Dr. Maffei applauds Health Quest’s commitment to bringing bariatric surgery to every patient who needs it.
“The truth of the matter is, we are changing people’s lives with bariatric surgery,” he says. “That said, we have reached less than 1 percent of potential patients who could benefit from this operation. Health Quest stands behind us as we seek to get the word out.”
To learn more, visit healthquest.org.
*The physician identified is neither an agent nor an employee of Health Quest or any of its affiliate organizations. This physician has selected our facilities as the place where he wants to treat and care for his private patients.