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Christian Birkedal MD

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The Chicken Or the Egg?

Discussing mental health and obesity can be tricky, because you often run into the question of, “which came first.”  Mental health issues like anxiety and depression can lead to overeating and obesity, but is it sometimes the reverse? Does being overweight or obese make people depressed and anxious?
Do overweight patients suffer from a higher than average chance of depression and or anxiety? Read “Obesity and Mental Health.”
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Minimally Invasive Breast Surgery

Breast cancer is one of the most common and concerning health problems faced by American women. It is second only to skin cancer as the most diagnosed malignancy in female patients. Currently, it is estimated that about 1 in 8 American women will develop invasive breast cancer (cancer that spreads into surrounding tissue) sometime in their lives.
This means that more than 266,000 new cases of invasive breast cancer will be discovered in 2018 alone. In addition, there will be an estimated 64,000 new cases of non-invasive or “in situ” breast cancer (a cancer that does not invade surrounding tissue). These non-invasive tumors are not life-threatening themselves, but having them can increase the risk of developing an invasive breast cancer later on. Those two statistics are the bad news, but there are several pieces of good news as well.
First, those statistics actually represent a decrease in the number of new breast cancer cases compared to past years. The numbers began decreasing in the year 2000, after having risen for the previous two decades. From 2002 to 2003 alone the number of new cases fell by 7%. Many scientists feel that this decline was due to the reduced use of hormone replacement therapy (HRT) after the results of a large study, the “Women’s Health Initiative,” were published in 2002. These results pointed to a connection between HRT and increased breast cancer risk (see “Evidence-Based Medicine”).
The second piece of good news is the advent of minimally invasive breast surgery techniques that have made many surgical procedures such as lumpectomy safer and more acceptable to the patient. In the case of breast cancer and surgical breast cancer treatment, minimally invasive surgery has substantially improved the patient experience. This involves much more than simply performing the surgery through small incisions. Minimally invasive breast surgery aims to improve emotional and psychological health, as well as to maintain or improve purely medical outcomes. Minimally invasive breast surgery does this by:

Minimizing the side effects of surgery and reducing treatment complications
Speeding return to normal activities
Preserving breast appearance

Minimally invasive breast surgery is especially important in improving the emotional and psychological health of breast cancer patients. Most patients never think about their gallbladder or their appendix, but surgery for breast cancer is different. It can have a serious impact on the patient’s body image, emotional state and psychological health, as well as their medical condition. In that sense, minimally invasive surgery may be more beneficial in breast cancer surgery than in gallbladder surgery or hernia repair surgery.
Minimally invasive lumpectomy is the surgical procedure in which only a part of the breast is removed to eliminate a breast cancer. Lumpectomy is different from mastectomy, which involves removal of the entire breast. Many women who are diagnosed with breast cancer are candidates for a minimally invasive lumpectomy. Lumpectomy preserves breast tissue and usually avoids the need for breast reconstruction. This minimally invasive breast surgery is done using small incisions in discreet places, resulting in minimal scarring. Lumpectomy also requires removal of a narrow “rim” of healthy tissue (the clear margin) surrounding the cancer, ensuring that the entire cancer has been removed.
In the past, lumpectomy has usually required follow-up radiation therapy to reduce the risk of cancer recurring. These post-surgical radiation breast cancer treatments may involve hospital or medical center visits that extend over several weeks. Typically, patients return to the breast cancer treatment center five times a week for five to six weeks. This imposes an additional burden on a patient who may have job or family responsibilities to which they must return.
A new form of radiation therapy, “IORT” (Intraoperative Radiation Therapy) can provide an alternative that is effective in preventing the return of cancer. During an IORT procedure, the radiation part of breast cancer treatment is delivered as a single dose in the operating room. IORT is now available at major medical centers like Florida Hospital Memorial Center here in the Daytona-Volusia area. See “Avoiding Radiation Therapy After Breast Cancer Surgery.” IORT combined with minimally invasive lumpectomy makes breast cancer surgery a far more desirable therapy for many patients.
Most women diagnosed with early-stage breast cancer are good candidates for minimally invasive lumpectomy and IORT.  Successful lumpectomy depends on the size of the cancer compared to the size of the breast, the location in the breast, and the skill of the surgeon. Minimally invasive breast surgery is becoming the primary choice for breast cancer patients who:

Have breast cancer in only one part of the breast
Have a breast cancer that is relatively small compared to breast size
Don’t have any signs of cancer in the lymph nodes
Are willing to receive radiation during the lumpectomy

An intelligent question about lumpectomy and IORT would ask if it is as effective as the traditional radiation given post-breast cancer surgery. In 2013, the British Medical Journal, Lancet, published the results of a 5-year trial of IORT in breast cancer. This study concluded that:

When IORT is given with lumpectomy, the 5-year rate of recurrence of breast cancer is similar to that seen with the traditional therapy.
Breast cancer mortality with IORT was similar to post-surgery radiation treatment
Mortality from other causes was significantly lower with IORT due to fewer deaths from cardiovascular causes and other cancers.

The primary goal of any breast cancer surgery is to remove the cancer and a surrounding rim of normal tissue. An important secondary goal is to support the patient’s psychological and emotional health, the “whole person.” Minimally invasive breast surgery combined with IORT goes a long way towards accomplishing both of these goals.
If you have any question about the areas included in general surgery, especially bariatric surgery, minimally invasive breast surgery or IORT, please contact our office. You may use Contact Dr Birkedal or phone us at (386) 210-9844. Our offices, located in Daytona, New Smyrna and Palm coast are all part of the Florida Hospital Network.
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What is Bariatric Medicine?

Given the growing problem of obesity in the United States and the world, it is surprising that we do not hear the terms, “bariatric clinic,”  “bariatric physician,” “bariatrics” or “bariatrician” more often. The specialties and subspecialties of medical practice have tended to develop in order to fill specific, sometimes narrow needs. Cardiologists deal with heart disease, nephrologists with kidney disease, ophthalmologists treat diseases of the eye and so on.
Medical obesity is a health problem that extends across a good number of medical specialties. Family practitioners, internists, gynecologists, even pediatricians find that they must deal with obesity as a primary medical problem or as a cause of things like heart disease, diabetes, joint disease or mental health issues. As medical problems go, obesity has proven to be a very difficult challenge. Medical science has made giant strides in preventing or treating infectious diseases, heart disease, cancer and numerous other conditions that have been causes of great suffering. No one dies of smallpox today, most Americans have never seen a polio victim and only older doctors have ever seen a “rubella baby.”
Obesity, however, is sort of like “That Old Man River,” it just keeps rolling along. It is not fair to say that obesity has stymied medical science; right now, it is beating medical science. Despite the best efforts of public health agencies, doctors, medical educators and drug companies, obesity rates continue to grow (see “Wrong Way, Jose” to read recent statistics).  The physicians who specialize in treating obesity are known as bariatric physicians. Some work in medical clinics dedicated only to weight loss (bariatric clinics) and others are in private practices, often as part of a Family Practice or Internal Medicine organization.
As of now, the American Board of Medical Specialties does not have a specialty or subspecialty called “Bariatric Medicine,” perhaps because (as noted above) the problem spans so many types of physician practice. There is a professional organization called the American Board of Obesity Medicine which certifies physicians in bariatric medicine. This organization’s board includes several professors at well-known medical schools including Cornell University. This organization encourages research and physician education in the field of bariatric medicine.
Bariatrics is one of those fields of medicine in which the paths of physicians and surgeons sometimes cross. Bariatric surgery was once thought of as a mechanical procedure, resembling a plumbing alteration. The less obvious effects of bariatric surgery, the metabolic changes it produces may be just as important, or even more so. The gastric sleeve and gastric bypass procedures not only reduce the amount of food consumed and the number of calories absorbed, they also cause changes in metabolism.  Bariatric surgery can change the way a patient’s body deals with insulin, adjusts blood sugar levels, feels hunger and performs other important physical processes. Drug companies have invested huge fortunes trying to do this, but so far, without great success.
On the other hand, bariatric surgery continues to prove a reliable way to accomplish and maintain long term weight loss. If you have tried and failed to achieve your weight loss goals with diet, exercise programs or behavior modification, please investigate the possibility of bariatric surgery. Our office will be happy to answer any questions about the areas included in general surgery, especially bariatric surgery. Please contact us by using Contact Dr Birkedal or phone us at (386) 210-9844. Our offices, located in Daytona, New Smyrna and Palm coast are all part of the Florida Hospital Network.
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It’s never too early to remind you about the Monthly Bariatric Support Group Meeting

This meeting is held on the 3rd Thursday of each month at 5pm. It’s located in Dr. Birkedal’s Office at Florida Hospital Memorial Medical Center. For August, that will be Thursday August 16, 2018. If you are concerned about your weight, please plan to attend. The first step in solving your problem is to recognize it and discover the options for dealing with it.
Click Monthly Bariatric Support Group Meeting to get information and directions.
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The Early Signs of Type-2 Diabetes

Type-2 diabetes is a threat not only to individual patients, but to the entire medical care system. It is becoming a true epidemic, one that threatens to overwhelm the best efforts of doctors and public health officers.  This disease and its consequences are so threatening that the government’s Centers for Disease Control periodically issues a special report aimed only at type-2 diabetes. The “National Diabetes Statistics Report” is intended for medical and scientific readers, but the information it contains should be a matter of wide public concern.
Here are some facts from the 2017 edition of the report:

An estimated 30.3 million people of all ages (that is 9.4% of the U.S. population) had type-2 diabetes in the year studied, 2015. That number has surely increased in the past 3 years.
This total included 30.2 million adults, aged 18 years or older. This means that about 1 in 8 of all American adults had type-2 diabetes.
The percentage of adults with diabetes increased with age, reaching a high of 25.2% among senior Americans (65 and older). This is a special concern for us here in the state of Florida. Our very high concentration of senior residents makes this even more important.
About one quarter of the people with diabetes did not know they had the condition. This is especially worrying, because diabetes is a progressive disease that becomes worse if it is not treated. As it progresses, diabetes does irreversible damage to the eyes, kidneys, cardiovascular system and other vital tissues. If diabetes is detected late, it can be treated, but the damage already done will remain.
Besides the 30 million+ Americans who are diabetic, another 80 million are “prediabetic,” meaning that they have higher than normal blood sugar levels but not so high as to be called diabetes. If this condition is not corrected, it is likely to progress to diabetes over time; even fewer prediabetics are aware of their condition than is the case with true diabetics.

There is one way to determine with certainty if a person is diabetic or prediabetic: a lab test to measure blood sugar levels.  There are several versions of this test, such as the fasting blood sugar and the  “A1C”  test, and they can tell your doctor if you are diabetic, prediabetic or in the normal range.  The fact that so many people are not aware that they have high blood sugar levels must mean that they are not being tested, or that they ignore the results.
Whatever the cause, this is a dangerous situation.  The ideal solution would be for all people to get proper diagnostic tests at appropriate intervals.  What those intervals are depends on a patient’s age and some other factors such as blood pressure, body mass index or BMI and family history. Whether you are doing this or not, there are a few symptoms of early diabetes that can alert you to a possible problem. These diabetes warning signs include the following:

Increased urination – Normally your body reabsorbs glucose as it passes through your kidneys, but when blood sugar is higher than normal, it may not be fully taken back up. This causes the kidneys to produce more urine than they normally would and therefore increase the frequency of urination. There is a natural variance in how often a person urinates, but if you need to ‘go’ more than 7 or 8 times a day, it should be looked into.
Excessive thirst – This is the body’s response to increased urination. Because of fluid loss, you become thirsty frequently.
Extreme hunger even after just eating – Diabetics cannot regulate blood sugar effectively and thus, there are significant fluctuations in glucose levels. When these levels fall, the brain signals that you need more calories, even if you just finished an ice cream cone.
Unexpected and unintentional weight loss – Without proper glucose regulation, cells are deprived of new energy sources and the response is to breakdown muscle tissue leading to weight loss.
Unusual fatigue, feeling weak – Because of changes in glucose metabolism, sugar remains in the blood, depriving the cells of needed energy sources. Naturally, you feel fatigued and have less energy.
Tingling or numbness in hands or feet – Over time, high blood sugar levels damage nerves and nerve-endings. This shows up as “pins and needles” feelings, usually in the extremities.
Blurred vision – High blood glucose levels cause fluids to be pulled out of cells. This includes the eye lenses, altering their ability to focus.
Itchy, dry skin or darkening skin – This may be the result of poor circulation or excessive fluid loss. Darkening skin may be caused by a hormonal change (insulin resistance).
Slow healing of cuts or wounds – Over time, high blood glucose levels will damage the arteries and veins, reducing circulation efficiency. Because good blood circulation is needed for healing, this reduced blood flow will slow the healing process.

Being aware of these early signs can help to alert a patient to the possibility of high blood sugar.  The problem is that any of these symptoms could be caused by a number of underlying problems. This is probably truer in seniors. Vision changes, fatigue or tiredness and unexpected weight loss may be due to a number of age-related factors. Older men may experience urinary frequency due to prostate changes.
The bottom line is this: any of the above symptoms should be reported to your doctor and investigated. Relatively simple lab tests can tell your physician whether your blood glucose levels are within the normal range and if they are not, proper treatment should be started. The first line of that treatment will surely be diet and exercise, then medication. It is very important that this silent killer is not allowed to progress.
As a bariatric surgeon, I have a special interest in diabetes treatment. When first-line measures like diet, exercise and medication have not worked, the patient may be a candidate for weight loss surgery. Bariatric surgery procedures like the gastric sleeve or the gastric bypass have been shown to stop or reverse the progress of diabetes. If you have been treated for medical obesity and failed to respond to diet, exercise, behavior modification and medication, weight loss surgery may be an option. Please take a look at our video presentation, “Bariatric Surgery Can Prevent Diabetes.”
If you have any question about the areas included in general surgery, especially bariatric surgery, please contact our office. You may use Contact Dr Birkedal or phone us at (386) 231-3530. Our offices, located in Daytona, New Smyrna and Palm coast are all part of the Florida Hospital Network.
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You may be familiar with the term, “Binge Eating Disorder”

About 2.5% of the general population has experienced binge eating disorder at some time. That is not a high percentage, but studies indicate that BED is far more common in people who seek medical help for obesity. Read about the effect that binge eating disorder has on health by clicking Binge Eating Disorder.
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Latest Statistics for Bariatric Surgery in the United States

In June, The American Society for Metabolic and Bariatric Surgery (ASMBS) published the latest statistics for weight loss surgery done in the United States. Once again, in 2017, the total number of weight loss surgeries grew, increasing to 228,000 bariatric surgery procedures nationwide. Taken alone, this figure sounds impressive; it is over a quarter of a million weight loss surgery procedures done in a single year. Two decades ago, gastric sleeve or gastric bypass surgery was considered ‘experimental’ and almost unknown outside of academic centers. That has to be an impressive growth curve.
Within the broad class of weight loss surgery, the laparoscopic gastric sleeve continued to dominate the statistics, accounting for almost 60% of the yearly total. Gastric bypass surgery has declined as a proportion of total procedures and new lap band procedures have dwindled to less than 3% of all bariatric surgeries. The popularity of laparoscopic gastric sleeve surgery is probably due to the fact that it is a relatively uncomplicated form of bariatric surgery compared to the gastric bypass. It does not involve rerouting the course food takes as it travels through the digestive system and it has produced significant and long lasting weight loss.
All this said, we should add a note of caution. The total number of bariatric surgeries grew by 5.5% from 2016 to 2017, however the CDC estimates that the number of Americans with type-2 diabetes will triple (that’s 300%) in the 40 years between 2010 and 2050. Type-2 diabetes is just one of the serious medical conditions that follow in the wake of obesity. We don’t have statistics at hand for all these diseases, but it is not difficult to see that we are falling behind. The effect of increasing rates of heart disease, some cancers, diabetes, vascular diseases and the other morbidities due to obesity will overwhelm the medical care system if it is not stopped.
It is encouraging to note that both the gastric bypass and the gastric sleeve procedures have been shown to produce significant and lasting weight loss, but also to result in type-2 diabetics going into remission. Roux-en-y gastric bypass results in remission of type-2 diabetes in 80 percent of patients and improvement of the disease in an additional 15 percent of patients. The gastric sleeve procedure has shown remission rates of more than 60% and, in some studies, results similar to those seen after gastric bypass.
Deciding on the bariatric surgery that is most appropriate for a given patient requires a complete medical workup. Your bariatric surgeon will work with your primary care doctor, endocrinologist, bariatric clinic physician and other medical professionals to develop a treatment plan. An important part of the treatment plan is the post weight loss surgery support and help offered. This may involve professionals in the fields of nutrition, exercise and fitness, behavior modification and other areas, as well as your primary care doctor. Bariatric surgery, support from medical professionals and a committed patient can win this fight.
If you have any question about the areas included in general surgery, especially bariatric surgery, please contact our office. You may use Contact Dr Birkedal or phone us at (386) 231-3530. Our offices, located in Daytona, New Smyrna and Palm coast are all part of the Florida Hospital Network.
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Do you know that you are probably paying for obesity?

If you or your employer buys health care insurance, if you pay Medicare taxes or Part B Medicare premiums, you are paying for the cost of obesity. Insurance is a risk-spreading device, intended to spread the burden of health care costs over many people. When the risk is increased by one group, all the rate payers must pay more. Read, “Obesity and Medical Costs” to learn more.
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Do you or someone you know suffer from a hernia?

The term, “hernia” is sometimes misunderstood. A hernia occurs when an area of the muscular wall that normally holds in the internal organs and tissues stretches or bulges. Perhaps 80% of all hernias are inguinal (located in the lower abdomen), and inguinal hernia surgery is one of the most common of all surgical procedures. Find out about laparoscopic inguinal hernia repair by reading “Inguinal and Umbilical Hernia Surgery.”
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Avoiding Radiation Therapy after Breast Cancer Surgery

Modern laparoscopic surgery techniques have made surgical breast cancer treatment a far more acceptable choice for thousands of women. Because of this and other advances in breast cancer treatment, the prognosis for women with breast cancer has improved dramatically. A vital key to this progress is the early detection and prompt treatment of breast cancer.
Early detection makes lumpectomy (as opposed to mastectomy) the usual course for many breast cancer treatments. You may sometimes hear lumpectomy referred to as “breast conserving surgery,” “partial mastectomy” or “wide excision.” All of these terms refer to a surgery (often a laparoscopic surgery) that removes only the tumor and a narrow rim of tissue around it. Most of the breast tissue is left intact, and with lumpectomy, the breast looks as close as possible to how it did before surgery.
That fact alone made the idea of breast cancer surgery far more appealing to many women. However, the requirement of post-surgery radiation therapy remained for many patients, and this could be a major burden. Given after lumpectomy, radiation therapy is intended to rid the area of any cancer cells that may remain. Those cells are too small to be seen or detected by scans or to measure with lab tests. Many careful studies have confirmed that following lumpectomy, radiation therapy lowers the risk of breast cancer recurrence and breast cancer death. In fact, in appropriate patients, the results of breast cancer treatment using lumpectomy plus radiation therapy appear to be as good as with total mastectomy. Using laparoscopic surgery techniques, lumpectomy may be a one day procedure.
All of this sounds great, but the down side in many cases is the post-surgery radiation treatments. Post-surgical radiation breast cancer treatment can involve treatment that extends over several weeks. Patients must return to the breast cancer treatment center numerous times, typically five times a week for five to six weeks. A highly-trained staff and expensive medical equipment are required, meaning that this treatment is available only in larger medical centers. If the patient lives far from such a center, the problem of just getting to the treatment is a major obstacle.
A relatively new procedure called IORT can eliminate this problem for some breast cancer patients. IORT stands for “Intraoperative Radiation Therapy,” a procedure that can provide an alternative that is effective in preventing the return of cancer. During an IORT procedure, the radiation part of breast cancer treatment is delivered as a concentrated dose in the operating room. The need for weeks of follow up radiation therapy is eliminated.
This is obviously a great patient advantage and a cost saving measure as well, but there is a down side too. In order to be a candidate for IORT, the tumor must be detected early in the disease. If the tumor is too large, if there is more than one tumor or if there is involvement in the lymph nodes, Intraoperative Radiation Therapy is not available, and weeks of post-operative radiation cancer treatment must follow. This imposes a considerable social, psychological and economic burden on a patient who has already been treated for a serious disease.
In some cases, there are outside organizations that can offer some help with practical matters like child care, elder care, local or long-distance transportation and lodging. However, the best option is to avoid the need for post-lumpectomy radiation by keeping strictly to the guidelines for breast cancer detection. Women at average risk of breast cancer should have a mammogram once a year after age 40 to 45. If the patient falls into a higher risk group, she should have yearly mammograms along with an MRI starting at age 30.
Early detection screening exams for breast cancer identify abnormalities as early as possible, making more breast cancer treatment options (including IORT and lumpectomy) available. The odds of complete recovery are increased; if breast cancer is detected at an early stage, there is a 93 percent or higher survival rate after five years. The Daytona-Volusia-Flagler area has many fine early detection programs including those offered by Florida Hospital Memorial Medical Center, so by all means, follow the guidelines.
If you have any question about IORT or any area of general surgery, especially bariatric surgery, please contact our office. You may use Contact Dr Birkedal or phone us at (386) 231-3530. Our offices, located in Daytona, New Smyrna and Palm coast are all part of the Florida Hospital Network.
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