Chapters Transcript Video Management of patient care (from ERAS to PT) to support quality outcomes - B. Todd Heniford, M.D. Our next speaker is Doctor Hereford, and he's gonna tell us a little bit about management of patient care. All right. Very good. Yeah, thanks so much. This is, uh it's great to be able to get back together again. And, uh, and this course in New York is is always, always my favorite. And Peugeot. Thank you, Uh, from N W L. Gore for putting this on. And, uh and and this is again I mentioned my favorite course, and I'm gonna I'm gonna go hard to the hoop here. As my friend John Fisher says, uh, and I'm gonna just throw out a lot of information. And, uh, I'm supposed to talk about, like, the whole throughput of patients, including us and Physical therapy and all the things. And I'm gonna do it in 25 minutes, or I'll just stop talking when you give me the high sign about that. But one thing about this I will say that I am being put upon, and I'm looking right at you. Put upon with this because how can I possibly lecture without bacon? I just want to know how that is possible. I just don't know. I just don't know how we did how this is gonna happen, but I'm gonna like I'm gonna give extra effort here because there was no bacon this morning. I mean, I got up this morning. And what was I thinking about A WR? No, I was thinking about Bacon. And so anyway, if you see anything at all, that's that's worthwhile in these presentations, it comes from it comes from my fellows, and and so I I tend to go go hard at work, and, uh, we operate a lot. And so, uh, Janet, you got some big shoes to fill. But these are the 22 years of our fellows that that finished a couple of years ago and and have done great work. And and I'll tell you, like so doing abdominal reconstruction. No one grows up wanting to be a hernia surgeon. Nobody. When you were in your presence, you're like, I want to fix hernias. I absolutely I wanted to cure cancer. I wanted to do like things that were highly impactful and reminds me of this. This is you know, a friend of mine sent me this, Uh uh. And of course you can tell which one is me in this, but you know, it's it's hernias. Surgical specialists and surgeons and unicorns need to stick together. And of course, is that a plunger on your head. And so if you're gonna be a hernia surgeon and it got to the point that, like one of our past presidents of America's hernia society wanted to change the name from hernias, America's hernia society like to court health and because And it came from what I was told is that came from because somebody's had a cocktail party and you just fix hernias. I mean, let me tell you, it's gonna take a lot more than that to dent my ego. And they're gonna you know, and I'm proud to be an insurgent. I mean, like, plunger on my head, Whatever. Let's go. And so. But I will tell you, because of the specialization in hernias, that this is a slide that I wrote, and I sat down on a piece of paper in clinic in about 10 minutes. One of my fellows have graduated a couple years ago like let's talk about like all the mechanisms and all the breakdown and like being in repairing and doing down wall reconstruction, and I'm like, just wrote this down. But I did a slide just like this about 10 years ago, and it was one third of the length. And by being specialists by coming to courses like this and having conversations like this, we have changed the way we take care of patients in the most common operation performed in the world. And if I can't get excited about that, I mean, let's go. I mean, I'm a hernia surgeon, but you put all of this together, and then we start doing things like this. This is the largest peristyle mahonia I have ever seen. And you can see this is her. This line over here is her. This is her midline incision over here. And this is a pair of storm a hernia. And that right there, actually, you want to add some complexity. That's that's a that's a mess. Fistula on top of it. So let's I mean, like, my fellow walks out of the room at the time and she's like shaking her head, and I'm like, I want that, Whatever, whatever is behind door number one, that's going to be for me because let's go because I get excited about this stuff and this is her cat scan. And so if you look at her cat scan here. So, uh, here we go. This is she's got some of her solid organs in there, so she got a pancreas and her kidneys and her liver in her abdomen. But then there's a break out. I mean, it's just like a jail break, all of her intestine. And of course, I mentioned solid organs, you know, here comes her spleen. Hello? Because you were wondering where the spleen was. It's down about her mid thigh. And so so then the rest of her intestine, including wrist oma, is down there. And so this is what she looks like on the O. R table and so transition and get this patient taken care of. But this is what she looks like at the end. The combination of weight loss and Botox. We moved to Estonia, took down a fistula and this woman, and I'll tell you so this lady and you know, For 15 years she's had this hernia for 10 years. It's been massive. And so she has a loving family. She has two sisters and her mother, and someone is with her 24 hours a day because she can't get out of bed by herself. She can't go to the bathroom by herself. She hasn't had a job in 15 years. This is so This is seven weeks after her operation and and this is her. Adam's expanded a bit because what happens with Botox that allows the it takes attention off of your closure because of your obliques continue to expand when you put pressure on them. And two days later, she had she had her first job in 15 years. Why are we like hernia surgeon? Pick me A 100% chance, but I'll tell you 10 years ago, there's nobody in this room would have taken this on. But it is about the consideration of putting all those pieces together. And so it starts in the office and and to you know, who should be doing these. You know, if you don't do your big operations, just step back and send the send the patient to to, uh, to a surgeon who does or learn it. Or go and spend time just like this and talking to surgeons. Go go watch these guys operate. You're gonna see some fancy operations coming up. You know, spend some time doing it. Just like any operation that you'd want to take on. You know, 7% of our patients, we do abdominal reconstruction, and we'll end up in the icu. And if you don't have ICUs support and ready, Ready? Ready for that, then don't take the operation on. And I think John mentioned there were quality of life doctors most of the time. There are emergencies with hernias. Absolutely. Do we prevent emergencies? You know, 2277227 centimeter defects tend to get people in trouble more than anything else in recorded Michael James work. But the bigger hernias, for the most part, were quality of life. Doctors For England is you know, there's a .3% to 1.1% chance someone's gonna need an emergency operation. If you have an inguinal hernia. Were quality of life doctors. And so structure yourself to that. I'm gonna talk about CAT scans in a few minutes. This is a tool one. Things that almost all of these patients will get will be a cat scan and Then what am I? What else am I doing in the office? You know, and I'll tell you, like people in Comorbidities, and I'll speak about that for a second. You know, if you want to improve your outcomes, improve the patient's you're operating on, you know, for every square centimeter, every square centimeter. Now that we've done, we have a 54 100 open ventral hernia repairs in our database. I can tell you, for every square centimeter that increases the size of the defect increases complications for us and recurrence. Make the hernia smaller. How do you make the hernia? Smaller Botox. We mentioned the other was weight loss. And people like people won't lose weight. Have you? Have you tried to persuade your patients to do it? We even have an exercise program now, and I'm gonna talk about it for two seconds. In a few minutes, we'll that we've started that we do six minute walking speed at which equals distance. How far someone can walk in six minutes prescribes how patients will do post operatively, especially your older patients. And so how did you guys have said this is your walking program before your operation? we do now and then we also won another tool for our for our worst cases. And like and quite honestly, one of the things that I want to do is I actually want to make it so we can do R A w R conferences and have people from the outside attend. But you can see the people at the top here. You know, my partner federal organs, then it is a fantastic church in our fellow from last year, one of our radiologists. And then there's me. And of course I got this training saurus rex background and that usually so my mood is usually people can tell what my mood is according to my background on the So they know not to mess with me that morning. But then what else do we do in the office? Of course you're gonna plan your approach. The, uh getting the fashion clothes is super important, and it was mentioned about quality of life, and I'm gonna show you some more data about this. But for me, getting the fashion closed is super important because of complications and also because of failure. And I'm gonna talk about that. The other things that you might need to You might need to think about or down here, but of course, planning your incision. You know, I'm no plastic surgeon, but look at that one, John. Boom. I had to I just put that in there for you, but like, planning your decisions and getting these getting these patients taking care of him. Where did I like this? This incision right here, this kind of pear shaped incision. Where did I learn that from the guy sitting right here in the front. I'm like, Hmm, No, I did. And so this is one of the patients we have put it on that long ago. And again, it is about putting all of this together for your patients. And again, I fall back to quality of life. And I talked to the patients like these big operations. If someone and you know I'll say, Well, what do you do now? And they say, Well, I sit on the couch and eat potato chips and watch Netflix. Well, if I'm gonna put you through this big operation, what are you gonna do? And I'm gonna sit on the couch and watch Netflix and eat potato chips then perhaps I shouldn't do the operation. That woman that I showed you, I asked her. What are you gonna do if we fix you? If I'm gonna commit to this and the resources to do this, what are you gonna? She says I want to free up my family and I'm gonna get a job. Let's go and I'll tell you something. So they live five hours away, And Monday, two weeks after I last saw her or her family is in the waiting room and I show up on Monday morning. There's 22 people there and I'm like, uh, this is a problem. They drove five hours In four cars to come in and hug every single person in our clinic. And then they got their cars and drove home. Hernia surgeon Pick me 100%. So what are the things that we can control if you're not controlling smoking diabetes and wait and wait? It's hard, I understand. But for every point of bme, what this demonstrates is for every point of bme you decrease, you decrease the chance of complications. And I tell my patients all the time I want to cheat. I'm gonna cheat as much as possible. The other consideration is Like I used to think like when I was training residents when I was a resident, you had an Emirati me no big deal. We'll just sew it up and fix it. It's gonna be fine. Where if you actually look at our data, if you have an in Iraq to me in the operating room, you increase your chance of wound-related complications by 2.6 times. And I tell our fellows now it's not. Practice makes perfect. It's perfect. Practice makes perfect, and these patients are complex and, quite honestly, if you don't think they're complex. And this is like looking at component separation. So Sean Maloney I wrote this. He's one of our chief resident stable and he was in the lab. We published this two years ago, looking at 775 consecutive component separations. And so one of the things that I like to do and John mentioned this there's and and and and Matt mentioned there's such a variety of hernias And patients and sizes and all this stuff. What I try to do is heard patients together like like eliminate shuck off some of the some of the chaps so I can see it's my technique, really working. These are prepared meal mesh placements and component separations, but if you eliminate diabetes, you eliminate smoking. You'll be M. I have less than 35 and non contaminated. That eliminates 78% of the patients. These patients are complex, and you gotta like walk into your office and these patients and quite honestly, it's part of the reason that they're in their office in the first place. But if you look to the right, if you like in these patients, you pair this off. We have really good outcomes, but it's about doing this. You know, I used to be just a hurting your surgeon. I will tell you, if you're either going to specialize in this and do it for real or just don't do it. And so this is time commitment. This is what I used to do preoperative very short period of time. The operation length is the same, but my post operative care took a whole long time because of my complications. And now I just put this together and I'll tell you so many of you guys will know This book is the is the Love Languages book. And I have my hernia love languages. No one would pick up rehabilitation as your hernia Love language. Nobody would do it because we want to go to the or soap Rehabilitation is important for the big hernias. Yes, this is data from epic gastric hernias, umbilical hernias from the Danish group looking at smoking and look at obesity. And you look at the complications and you look at the admission to the hospital and even for the small defects, it impacts outcomes. How about for the big defect? So one of the things that we wanted to do is break off the fairly large defects to 200 square centimeter defects and less than 200 square centimeter defects. And if you look at this information, the for for the smaller defects, less than 200 square centimeters doesn't make a difference. Absolutely. Body mass index makes a difference. But you magnify this with the larger defects. So if you're gonna do the bigger defects, you have to be super committed to try to get people to lose weight. That's just the way it is. And so I know it's hard to know it's difficult, but heck you know it is what it is. And then also, too. If you look for diabetes, diabetes as far as wound complications and readmissions to the hospital, it's magnified by the larger operations that you do and just makes sense. And if you develop wound complications, this goes back to the paper that Sean Maloney did. If you develop wound complications, you can see our readmission rate and a hernia recurrence rate is magnified again because of wound related complications. And I put this slide in for John. This is looking at quality of life patients. This comes from an international study and Blair warmer. When he was our resident. He's now plastic church and actually in Charlotte. And when he was our fellow research fellow, you can see the impact and quality of life that complications make. And then this is a this is a fish paper demonstrating it shocks me that 19% of people have readmissions in one year looking at the National Readmission Database and two, you know, if you look at this, this is data from Dana Tulum from from the Michigan, uh, collaborative group, General Surgery Collaborative Group. Surgeons understand that this is important, but they have lots of excuses not to do it. And even this guy at the bottom down here, you know, I just like guidelines. I just make them up. I mean, and so what about adoption? So this statement comes from John Maxwell, who's a famous guru who talks about, you know, looking at effectiveness equals quality so effective as equals quality. Yep, we know the data's quality acceptance. We understand that it's true insurgents, except that it's true. But I'll add something here. Yeah, it's about performance, so you can say really good quality. We all, except it's true. But performance is zero, then effectiveness zero. Anything multiplied times zero is zero, and that's on us. And whose responsibility is it? The American College of Surgeons says it's ours, and so we have about weight loss. Everybody wants to talk about weight loss, but nobody wants to do it. And so one of the things that we do with weight loss is it does decrease your chance of complications, but it also makes your hurting us smaller. And so this is a native from, uh, from Katie when she, Katie Sasha when she was in our in our lab and she won the America's Journey Started Research Award with some of this stuff. But if you look at the change, just 11 lbs of difference makes a huge difference in someone's abdomen. Unfortunately for women, so in men it makes a huge difference in women. Not it makes statistical difference, but they need to lose more weight because they men tend to carry their weight in their abdomen. And this isn't a new concept. I mean, look at this. This is this was in the 1920s and presented the American College of Surgeons too much dieting before an operation. This is Wilson will cobb's data when he was a he was a fellow in our lab, and so does it doesn't make a difference. As far as getting the admin closed and and and so hurting a failure, a lot of it is just pressure inside this just a physics equation, pressure inside your abdomen. So you look at the people who are obese versus normal weight. You put a fully catheter in people and then he had to do 30 exercises three different times that collect all this data, But you can see the dramatic increases Intra Donald pressure in these patients who are obese. And then the cool thing about this is that was 20 people who were morbidly obese prior to having the gastric bypass. We got 30. I don't know how he did it because you talked 13 people into coming back after their gastric bypasses service, their own control and so a dramatic decrease in their into Donald pressure. So it's not just about your skills skills super important, of course. But I'll tell you, if you don't do this and you don't do that, and you only focus on this, you'll never be as good as surgeons you could have been. And so here as what is the eras, And people think it's an order set and to think about. It's about getting patients out of the hospital sooner, and it really isn't eras is not getting patients out of the hospital here, as is the best care, and this is an article in JAMA, and it's it's not about early discharge. It's about truly about applying the best science, and so I hate it when people say, Oh, here's our grass order set. I mean, that's not all of the era's. It's about putting it all together. And so this is our failures. And so this is like things that we've changed over time since 2000 and six, and all of this came from studying our own our own data and demonstrating how we can improve and is that era's absolutely it's eras. And so if you guys can take a picture of this if you want and if you if you want, I'll send it to you. My email address is todd dot robert at gmail dot com. Just my name and I'll send it to you if you want, but Janet puts this in like, 25 times a week, and it happens. But taking care of a patient like this, it's not just about what happens in the ore you go, John. It's all about like putting this puzzle together and then boom, do do you like that? It's putting all those pieces together to take care of this special for you. We're always competing about what kind of slides we can make, so but the other thing I did, I made it so. But It's also holding yourselves accountable. Like if you have partners and you're gonna do this so someone is responsible for this and all the patients that we operate on that we take care of every single patient. This is built out by our. We have a master's level nurse who helps take care of Donald Reconstruction patients, and she tracks this in every one of our patients and you have to take responsibility, have to hold each other accountable. And you know, it's not just, you know, this is over 100 years old. This is a surgeon who was who was president of the British Medical Association. And it's not about empiricism. Oh, this is what I think I've seen in my own practice or observation. It's about applying science, and that's what the races and hasn't made a difference for us. Absolutely, it has. And so we look at if you break down five years and then another five years later and you look at interpretation, the patients are hurting is essentially the same. But the patients are more complex and so how have we done? We've dramatically improved the way we take care of patients, dramatically improve what our outcomes are. We're constantly grinding on this. And so what makes a difference if you look at what makes a difference here, BMI, You know, it's always a struggle. So and we've we've now to have three studies where we broke down b m i with a lot of patients. It was, you know, point Oh, six point oh seven. And now point Oh four for you know, for every point of B. M, I increases the chance of complications and what I want you to show. What I want to show here is that, like you should say, Hey, Todd, look at this mesh type and and diabetes and smoking. How about diabetes and smoking? It doesn't make a difference. So why don't why doesn't diabetes and smoke and make a difference anymore? Because we don't operate on smokers, so we've eliminated it as a risk factor. They gotta stop for four weeks and diabetes. Hemoglobin, a one C F seven to our initial data for our cedar upset him globally. We want a one C of 7.2. Mate was a break point for us. We've held a line there, and now diabetes doesn't matter. anymore. It confirmed the data that we had for the cedar app Because I was not a very good surgeon. Like in 2013. The number one reason the number one point pointing thing for me to have complications after this operation was diabetes because I paid no attention to it whatsoever. I had no idea what a hemoglobin a one C was. Well, maybe, but I didn't. But I tried to forget a couple of other things. Uh, see, I'm going for 19 minutes. I got a few minutes left. So a couple of other things like walking. Do you think walking makes a difference? How many of you guys give your patients a walking program? Valody but six minute walking speed, as I mentioned earlier. Especially if you're older patients predict outcomes from major surgery. And so we now have a grant, and I say, Whenever you hear me say we, it's because I had nothing to do with all the work. But I will take credit for someone else's work in my lab. I say I a lot, but you know, But so, uh, Celia Yuzo now has a grant from the American from the American Hernia Society. And so now in this program we have, we have. If you want, I'll send it to you. We have a program for and he What we do is we take a patient for a six minute walk at the time of their clinic visit, and we show them how slow they are because people think they can walk forever. Most of them do. Then we give them either give them a pedometer or show them how to do it on their phone, and we give them a walking program, and so far we've had 100% compliance. Average weight loss is £15 and they can increase their their distance by 900 ft. So in the morning, they show up for surgery, were taken for a walk again, and so but take the commitment of taking them for a walk prior, like we're going to commit and say, You hear me saying we again? It means I didn't do it. We are going to commit by having someone walk them and demonstrate to them, and then they commit. We do things like like narcotics. We've measured narcotics and narcotic use, and in our patients and so through this, we've actually substantially decreased the amount of narcotics. And we've also through the hernia center. We now what? Most of our general surgery services are now doing what we did for narcotics. And if you want this, I'll send you the paper. But now you know from our partners I mean, we try to comply to this, and then also we talk to our patients about national issues and then and then also to how many. You know, if you get a new knee or new elbow or new shoulder or you have rehab, we can reconstruct someone's Adam. We just tell them, Don't live for six weeks, you know, don't do any core exercises. Don't play golf for six weeks, and then you can kind of do what kind of do what you want. We now have a rehab program that we're that we started looking at our patients. We have two PhD physical therapists that are designing this, and it starts post up day one in the hospital for component separation and the things that are important and your component separation versus post your component separation and, you know, and your component separation in our hands has a substantially increased chance of wound related complications until we do vessel sparing. And Matt talked about vessel sparing, and we can certainly talk about that more. And wound complications yields recurrences like I showed earlier. But getting the fashion closed is super important. If you look at her, the recurrence rate hernia recurrence, if you don't get the batch of closed is seven times higher. It's even more important than wound complications. So into your component separation. The answer is absolutely I believe I get more released with the entire component separation. And if I can't get it, get the abdomen together. I don't think I'm getting together with a tar. I absolutely go to go to that. And again, this is the multipolar analysis from, uh, from that study getting the fashion closed. And this was mentioned by John in our data. If we don't get the fashion closed, increased chance of recurrence. This is Michael Yang. If you look at the S S. O. S. And in recurrence rates significantly impacted by getting the fashion closed. I mentioned earlier. One of the things that I want to do is I want to get the fashion closed one of the That's my goal. One of the goals I said in the in the office bridging I will bridge, but it's like playing horse. I got a call that before the shot. Otherwise, I'm trying to get people closed. Might, uh, Mike Rosen agenda Prabhu cover previous fellows, you know, and it takes It takes bravery to show this doing. Tars. Where? Where they bridge a 46% recurrence rate in these patients by experts. But they also showed it significantly impacts quality of life. Dude, you are my hero. Okay? Starting. I think I can finish. I'm gonna go fast. I'm gonna go really fast now because I got to eat a Yeah, here we go. Boom. I love it. Hey, for whom and so but it is about getting trained into one of the problems is And your guys, you wouldn't be here so on a Saturday without being committed to this, if you're gonna spend your Saturday and so it's about, like taking hernia seriously. And so this is a study, uh, survey by Yuri Nowitzki when he did it to the H s, a 75%. Very few people learn to turn the rest, but they talk about number of To master a tar 65% of the people since 1 to 10 cases. I'll just tell you, we have fellows who actually do this operation over and over and over again. And then when they get into the get into their, uh, their practice, they still call and talk to me about about technique. The deeper you get in this, the less you understand. The less, you know. And people have to take this seriously because I used to make a living doing component separation. Now make a living taking care of component separation complications. And I just like over we see these over and over and over again. And then you get a case like this where the guy had a bilateral external oblique release right through the similar nearest cut. All the nerves that Matt talked about. So the midline. This is exactly one of the things that comments that Matt made you got. You got the midline together. The rectus muscles are actually still together, but they're dead because there's no nerve supply to them. And so it looks like this went out when we go to fix them. And so I mentioned earlier about, and I'm gonna stop you in just a second. I mentioned earlier about, like, the transverse abdominals versus inextricably police. And we can have a debate. Maybe you guys think the tar gives you the same as an extra biblical. As I say, it's absolutely not true. And And this is data from from Yuri. So if you cut the in what this demonstrates if you cut the post director sheet, you get most of your release by cutting. Oh, if you're gonna take a picture, take a picture of it. Now, take that picture. Yeah. Giddy up. Wait, You didn't I'm just kidding. No, I'm not, actually. Okay, But you get most of your release about cutting the post director sheath. So and again, we talked about this, but perpetrator sparing. And I think this is super important. And then this has changed our practice. And so it's really described. There's actually a couple of descriptions in Chicago And also the guys MD Anderson, Chuck Butler and MD Anderson. And this is what I used to do. I would crank the car up to 60, turn the music up and blow through the abdominal wall. And look how good a surgeon I am, you know, But we need to base our I mean, it's like who knew blood supply was so important. Gotta We need to base our flaps on these on these perpetrators. So now, even when I developed skin flaps, I'm kind of looking for these guys to improve our outcomes And even like there's the secondary when someone's already had an extra oblique release, we still are looking for these secondary perpetrators out lateral. And so if you look at our into your component separation versus the perfect or staring into your component separation and just look at the change in the complication rate and then we compare this to Tara and I'm gonna stop after this and again great work by, uh, Sharm el el Hajj, the shark who was in our lab two years ago. And if you look at the pro fighter sparing versus tar, if you come down here and it actually evens it out, So I'm gonna stop here. We've got other things that I might throw in here later about Botox. If nobody talks about Botox because we've got some data about where where it's most effective and how we use it. And, uh and I look forward to the rest of the morning and thank you very much, guys. Yeah. Okay. Dr. Jennifer, Thank you for that. Very interesting talk this morning. Opened up to the audience. Struck gold last. How often do you end up canceling a case? Yeah, you know someone there, you know, there. Sure, it's not a whack there. They start. Yeah. So smoking is the biggest one. And so that I will cancel if they're smoking. And I probably do this. It's probably not more than once a quarter once every two months, but I will. And I've had patients get just mad as they can get because they and I'll just tell them we had a relationship well, and so you can lie to me if you want, but if I know and I'm supposed to take it, I lie to you and you sue me. Yeah, we either have a relationship or we don't like, I'm not going to beat you up. And I tell the patients, if you start smoking again, just call me. I'm not your mother. And I'm not your minister. I'm not here to judge you and I'm not going to beat on you. But I want you. I want you to have the best outcomes possible and I'll get out like that. But we will have people that are smoking and we'll cancel. But that's the biggest thing. And then we have people who will lose weight and then when they show up in the office, and then four or five weeks later they're on the O. R schedule and then we weigh them and they gained, gained the weight back and they'll gain like £15 in like, five weeks. I'm like, What are you eating? Bacon? And so Getty up and I'll cancel them. People gain their weight back. I'll cancel them. Absolutely. And we've had people. I mean, even last week, I'm like, Check that, guys, Wait. And then he had lost weight. Time, right? Use medications at all. Personally? No. So if we're going to do that so we we make a run into patients, I just I sit down, describe the ketogenic diet to people, and I was like, Look at him and I just say I give my own personal history I had a patient challenged me about nine years ago and I lost. I lost 40 lb. I mean, I got down, I got down really thin and, uh, because she challenged me. And I'm like, she didn't told me. I didn't know anything about weight loss. I'm like, Let's go. And so I did the ketogenic diet and walked and but I described him. Why the how the ketogenic diet works and how it actually takes in our genetics into account how we're supposed to be hunter gatherers and genetically, we've never caught up with having a grocery store. We haven't 70,000 years as hunter gatherers, but but and and so we make a run at him. And then if they can't lose weight and their follow up, then we'll send it to a dietician and people who will just say just say, Oh, I can't lose weight can't do it. We send them to our Barry attrition. We won't even like they immediately go to our very attrition. So then and then we send 100 and more than 100 and 40 people for for bariatric surgery. So God bless the sleeve because we've had a lot of people. The problem is, is that some of our Bari bariatric surgeons fix hernias. And so I'm just like, Daddy's gotta eat, so you gotta send the patient back, so yeah. Bariatric surgery. Absolutely. Yes, sir. Course. Right. Yeah. Here. Mhm. Something for a short wait for Sure. Good. Catherine. What? Yes, It. Uh huh. It's really You are. I mean, you're absolutely right. So people lose weight. And and we will recommend that patients change their diabetic medications, but they lose the way. So we've had 247 recurrences People like are you kidding me? The answer is, yeah. 247 recurrences in our program. That's out of 50/50 400 operations. So the recurrence rates about 4.8%. And so and when we break these down weight gain and we tell the patients if you gain a lot of weight, your operation will fail, And we've had people gained over 100 lb, like 11 people gain over £100 and they just split their mash or rip it off their abdominal wall. And so But I tell them, like gaining £10 after your operation not really gonna matter, but you start to gain, like, £30 You know, and I don't have the data to be able to say £30 makes a difference, but we start to see increased recurrences in those patients. Physics wins. I mean, it's like blowing up. Yep. Thanks, guys. Thank you very much. Thank you. Okay. Published December 15, 2021 Created by
