The Lap-Band in a Private Practice with Dr. David DavtyanMD
Vernon Vincent: Hello everyone! My name is Vernon Vincent, I’m the medical affairs director and professional Education manager for Reshape Life Sciences. My pleasure to prepare a series of interviews for you and explain from a different perspective why you might be interested in including the Lap-Band in your practice as you leave your fellowship. Today’s interview is with Dr. David Davtyan from the Davtyan Medical Center for Weight Loss and Wellness in Los Angeles, greater Los Angeles area, and many years of experience with the Lap-Band from a private practice perspective, Dr Davtyan, good day! How are you, sir?
Dr. Davtyan: Doing very well, how are you?
Vernon Vincent: Great, great thanks very much for your time.
Dr. Davtyan: Thank you
Vernon Vincent: Yeah, the audience as we’ve discussed are surgeons who are just finishing their bariatric fellowship and kind of a perspective today as to from you that might interest them: is why would they be interested in including the Lap-Band in their practice, why would they like to diversify, actively engage Lap-Band patients so that’s sort of the backdrop. First, I will go through a few questions with you, how did you get into bariatric surgery initially?
Dr. Davtyan: Well, initially, I got involved because of personal reasons. I had a Lap-Band myself in 2001 before it was approved in the United States. I attended a conference where Ghiber Narcadier presented his data from Belgium, and my background was actually a fellowship-trained surgical oncology, so I trained at MD Anderson, the jungle in cancer institute, so i was doing very high-end cancer operations, liver sections cryo-ablations, etc, and you know from the stresses of life my weight had also expanded, I’m not immune to the modern era diseases, so I attended this conference not because of the obesity, I attended because of it was called minimally invasive surgery and it was held by the Phil showers. And during that conference I heard the lecture on Lap-Band presented by Narcadier, basically shocked me that you know 15-minute procedures, that’s how long his presentation was with the video and everything that such a minimally invasive procedure that does not even alter your anatomy significantly can make such a tremendous impact on one’s well-being, address obesity as well as comorbid conditions. So I went to Belgium, I trained with Narcadier, and I spent time with him. I watched him operate and then once I was, you know, I confirmed my initial excitement about the procedure. I went ahead and had the procedure myself. And after that it basically, gradually, overtook my practice, so now primarily what I do is bariatric surgery
Vernon Vincent: So that’s 20-year history with the Lap-Band
Dr. Davtyan: Yes
Vernon Vincent: Well, very good and your personal experience then translated into your clinical experience with your patients in Los Angeles. Tell us a little bit about how many patients and generally how they’ve done?
Dr. Davtyan: Well, l’ve done probably about Lap-Bands, 2500 plus a smaller number of sleeves, but I do both and as well as gastric balloons. I do not do bypasses and my current sort of practice is probably 60 70 percent bands and 30-40 percent sleeves.
Vernon Vincent: And your day in the office, what does that look like typically
Dr. Davtyan: Oh, my day, by day in the office can be in this covered environment, rather complicated but in general we see a lot of new patients, obviously, we see a lot of returns, we see a lot of adjustments because Lap-Bands constantly need attention and so that’s pretty much it. I do have several offices, I have one in Beverly Hills, one in Glendale, and one in rancho Cucamonga, which is an inland empire, so I do cover a very broad territory and am very busy.
Vernon Vincent: So, the aftercare and the constant follow-up that you just mentioned, it’s described entirely in two different lights, one is a real advantage, a benefit of the Lap-Band that is adjustable, it’s fine-tunable that you can accommodate a patient’s lifestyle. They get pregnant, you can deflate as necessary etc. On the other side of that coin is, oh my god, there’s so much follow-up that’s required, so many visits, all these adjustments. Is there a perspective on the middle of that line or a reason for the viability of your office as well as for the success of your patients that the follow-up continues to happen.
Dr. Davtyan: Well, the follow-up is very, in my view, follow-up is important in any aspect of medical care. As I mentioned I was brought up as a surgical oncologist in the premier center such as Andy Anderson or John Lynn Cancer Institute so very, very, close follow-up particularly in oncological patients, where you know, if I did a mastectomy then that patient was mine for the next 20 years and I would do very, very, close follow-up to mention, make sure that they’re not recurring, to make sure that the chemo work, to make sure radiation works et cetera, et cetera, so I was like the conductor of the orchestra. So, I still maintain that same view in my practice of bariatric surgery, I think obviously is a chronic disease I don’t think it is going to go anywhere until we come up with some drastic pharmacological or genetic or some biological very specific intervention, surgeries are rather crude ways of dealing with this disease, but those are the only ways that we have now that are affected and no surgery is better than the other one I can tell you outright because stomach is elastic so it stretches no matter whether it’s the pouch of the Lap-Band, the pouch over and why gastric bypass or the sleeve itself. Stomach is elastic, it stretches so if patients eat more and more, they are going to stretch it more and more so there will be some recurrence of the weight with regain and somebody needs to follow these people very, very, closely to make sure that you intervene in an appropriate times and so close follow-up is very, very, important no matter which procedure you do. So, I do not subscribe at all to the notion of sleeve them and leave them. I think that’s a very clinical approach and it does not reflect what we’re supposed to be doing. Any sleeve patient will do better with chronic follow-up and chronic follow-up is just, it’s good, it’s important you learn more about your patients. You get an opportunity to correct their mischief, let’s call it if they are sort of increasing their oral intake or gravitating towards high calorie intakes, and you get an opportunity to fix it, to advise them to change, you get an opportunity to interfere, to prevent vitamin deficiencies, etc., etc., so there’s numerous opportunities to impact patients’ livelihood with close follow-up and that’s why I do it.
Vernon Vincent: The oncology model is a very, very, salient one. Surgeons who’ve started over the years have asked for what kind of nurse can I find to help me do this, and I tell them to go find a burned-out oncology nurse, somebody who’s really likes patients, talks to patients, holds their hands all the time, but is burned-out because their patients have always, demised whereas Lap-Band patients, weight loss surgery patients can get better over time, it’s a rewarding situation.
Dr. Davtyan: Would you say that you did it indeed, and it is also rewarding on multiple aspects. I mean, one of the frustrating parts I guess in oncology was that no matter how good your operation, there was nothing to show for it. Your good results would be seen or measured as a five- or ten-year survivorship, whereas here with obesity, you know somebody loses 100 pounds. It’s very, very, visible and gives us joy to see these people back in our clinic.
Vernon Vincent: Great! So from the young surgeon about to start a bariatric practice, he’s gone through all of his training, fellowship and now he’s about to launch and land somewhere. Why should that individual think about adding either access for follow-up for patients, or new band patients? Why should diversifying their practice with the Lap-Band beyond their mind?
Dr. Davtyan: Well, first of all, the obesity population is not a uniform population, it’s a very large and very diverse population, number one. Number two, there are different modalities currently available from the band to the balloon or actually the reverse order going from the least invasive would be the balloon to bands to sleeves to bypass to bpdds so clearly one should be able to do any one of these procedures and be able to offer them as long as they share the value of that procedure. I offer balloons because I think there is a subset of patients who will do very well with the balloons, people let’s say who are typically or normally are not obese but due to some circumstances in life such as pregnancy have gained 20-30 pounds now, they need a quick uneventful or non-surgical intervention to drop those 20, 30, 40 pounds. I think ballooning is a very, very, good method for those, but if patients are coming and asking me for 80-90-pound weight loss and are hoping that the balloon is going to accomplish it, that’s not at all the case, and that comes a turn for the Lap-Band. Now, in a sort of more commonly done procedure, let’s say sleeve and bypass, Lap-Band next to him can be and in my hands is equally effective. You just need to do proper patient selection, proper patient education is of utmost importance, and then once these patients are properly selected, properly educated and with proper follow-up you can get amazing results, be it either the amount of weight loss percent of excess weight was let’s say or the speed with which you can get it or longevity. So, you know the largest number or greatest number of weight was pound wise. I’ve had people lose 200 plus 250 260. We’ve had that lose and maintain it for a decade sure we’ve had that too, lose quickly or lose slowly that’s in your hands because Lap-Band has that beautiful ability to do the adjustment. So, if you have a healthy patient who is otherwise okay and wants to lose it quickly, you maintain the tightness, pretty tight and then they lose a lot fast or if you have somebody who needs to go more gently, you can adjust it and do it more gently. So, lap band is the most versatile of all of those operations that I mentioned, it is clearly the safest, I mean the mortality of the Lap-Band does not come even close to mortality of sleeve and bypass and if I am going to give this patient informed consent and I’m going to tell them that, hey, the mortality of sleeve and bypass is this and this and the mortality of the Lap-Band is this but five years later your weight loss is going to be 60 70 percent excess weight give or take. With either one of those procedures, clearly, patients are choosing what is safer.
Vernon Vincent: And you find today that in Los Angeles, given the information, given the opportunity, can you explain the options patients are asking for lappings.
Dr. Davtyan: Patients are asking for Lap-Bands, first of all, I have very educational websites. The website that’s more in-depth for the Lap-Band, it’s called lapbandla.com and that website is very in-depth, provides an opportunity of hearing patient testimonials, seeing patient videos. I also provide my patients an opportunity to speak to any one of the patients. I mean obviously I have a very, very large number of patients. Out of 2500, I’ve got hundreds of fantastic results which are showcased one way or the other, and of course when patients see those results they’re saying, wow, this is great, or this is nice, or this is whatever I thought you want to talk to this patient, I’ll be happy to connect you. So, I think that’s very, very, important for patient reassurance, patients, this is very important decision making for them so they need to know that there is a team that will provide them information, but that there are also others who have been through it and will be willing, and able to share their experiences so that is very, very, helpful.
Vernon Vincent: The last topic which is sort of the flip side the front end of this an audience might say wow that’s all sunshine and unicorns. What about problems? What about complications? Patients that are five-ten years out or patients from somewhere else that are ten years out for any procedure, tell me, just compare, and contrast briefly the issues with all procedures down the road, and how you prefer one or the other or what do you think about them?
Dr. Davtyan: Well, it’s hard to do it briefly, but the basic message is this: so, if you look at what are the real complications that can happen, okay, intro post-op or long-term well the Lap-Band does not cut viscera so you’re not crossing the intestinal barrier, so they operate the likelihood of infection or a catastrophic infection is very, very low very, very low. So, you just wrap a band around the stomach. It’s a 30-40-minute procedure, they go home in one hour. You do it on a Friday, they can go back to work on Monday, brag about their new diet, nobody needs to know anything happened to them, and it does not affect their ability to perform their work either. With a sleeve, it is definitely much more involved, the operation is longer but as far as probability of complications it is much, much more complex. I mean we sugarcoat it, calling it a gastric sleeve although it is an appropriate term, I guess descriptively it does not at all reflect that we’re basically doing what is otherwise known as subtotal gastrectomy.
This is a major, major operation, you’ve got a 30-centimeter staple line that could leak, there are a lot of vessels that are divided that could bleed you’re operating in vicinity of spleen that can get traumatized, you’re operating in vicinity of pancreas that can get pancreatitis, you’re operating in the vicinity of mesenteric vessels, that you can get mesenteric vein thrombosis, and then portable vein thrombosis and that patient’s life is screwed up.
So, we’re talking about very, very high-risk area of operation and very, very high-risk operation altogether and that explains a fairly high risk of mortality that’s across the nation available through asmbs website, and clearly the Lap-Band does not even come close to that and then when you look at the long-term complications, well, the sort of most common complication of the Lap-Band is that the pouch which is above for the area of the stomach that is cardia, above the band it can stretch, okay, and if it stretches it pulls the stomach up from below the band and if I make it a size of let’s say, a chestnut immediately after the operation, several years later, it become a size of a tangerine and then the band will stop functioning properly. At that point you need to intervene, and that intervention is much, much safer than an original sleeve. All you need to do is go back in surgically, obviously, open up your band, reduce that prolapse to segmental stomach, refasten your band, re-shoot yours, put the suture so it does not slip again and hope that the patient learned the lesson is not going to abuse it, whereas with sleeve if you get a dialysis dilation of the sleeve, what are the options: re-sleeve or move up to a much higher complexity operations, such as white gastric bypass which has higher morbidity and mortality rate. So, clearly either short-term complications internal complications, post-op complications or long-term complications these operations are far and far behind and if you look at the five-year weight loss, if you do proper follow-up and keep your band fairly tight, you can get, I mean my patients are enjoying 60-65- percent excess weight loss after five years, well, guess what that is what I’m seeing with the sleeve patients, also, it’s not like a sleeve is a panacea I mean it’s a very good operation for some people but it’s not a magic and clearly there is a group of people who would benefit from one group of people who would benefit from the other but my philosophy is because the band is the safest I think any bariatric surgeon should start with a band, do the band first in all commerce and see what kind of weight was you can squeeze out of them and those who failed them because it is reversible five six-ten years later remove the band, move on to the next stage, obviously is a lifelong disease. So, you can move on the leg the next stage ten years later and if your sleeve fails in another ten years maybe you can move on to a bypass, but I think we should always start with the safest.
Vernon Vincent: Well very much appreciate that perspective, the continuum of care concept that is so common for instance in your oncology background, the starting with the least invasive and working up so with that David, I really, sincerely, appreciate your time these short little interviews hopefully will help people understand the perspective as to not only why you continue to do bands but why many still do across the country and why they might consider having a look at it. And it’s their choice and we hope that they, at a minimum, learn how to manage Lap-Band patients such as yourself. If you walked into their office on a Saturday afternoon you would come out with your band. David, really appreciate it, thank you so much!
Dr. Davtyan: Thank you Vernon, if any of your fellows will have further questions or want to reach out to me, I’m very available so please provide that access to them, so if they want to ask more questions or discuss this topic further, I’ll be more than happy to accommodate
Vernon Vincent: Absolutely, real pleasure, you have a good day sir! thank you very much!
Dr. Davtyan: Good talking to you, thank you!
