Weight Loss Surgery

Hello. I'd like to welcome you to this online presentation on bariatric surgery. My name is Dr. St. Laurent and I will be discussing the various aspects of obesity as well as weight loss surgery. As I'm sure many of you are aware, obesity has become a major epidemic in our country. Now more than 30% of Americans are considered obese. The actual rate of obesity has doubled over the past 20 years with one of our fastest growing segments now being children and adolescents. As a result, we have seen a substantial increase and the need for bariatric surgery in our country. How we determine if an individual is obese is by calculating their body mass index or their BMI. BMI is a measurement of body fat based on patient's height and weight. Unfortunately BMI does not differentiate between body fat and muscle. As an example individuals with the large amount of muscle such as a body builder will have a higher BMI, but not necessarily be considered overweight or obese. There are various levels of BMI with normal individuals being roughly between 18 and 25. As far as which patients are actually candidates for surgery we will tend to focus on the latter two groups with BMIs greater than 35. The actual definition of morbid obesity is an individual with a BMI that is equal to or greater than 40. However individuals with BMIs between 35 and 40 are also considered morbidly obese if they have developed a serious underlying medical condition. These medical conditions would include Type II diabetes, arthritis, the weight bearing joints, high blood pressure, heart disease or sleep apnea. In addition to these major health risks, we know there's a significant risk to a patient psychological and social well-being and there are also a multiple difficulties with their day-to-day function and their overall quality of life. Furthermore, being morbidly obese substantially decreases an individual's life expectancy by as much as 5 to 10 years. Compared to a normal weight individual, obese individuals have a 50 to 100% greater risk of dying prematurely and unfortunately this risk only increases as one's weight increases. Obesity has also had a substantial impact on our healthcare cost, not only to patients, but to health care excuse me, health insurance carriers. And because of the numerous factors that play a role in obesity, most non-surgical therapies have very poor long-term success. There are many factors that play a role or contribute to the disease of obesity. We know that the genes you inherit from your parents as well as your metabolism do have an effect. Additionally other factors such as your eating and exercise habits contribute to obesity, not only the quantity of food one eats but also the quality and how a patient eats. As an example, individuals who eat a large quantity of fast food or eat large meals late at night are definitely more predisposed to being obese. Psychological factors also play a role. Factors such as depression or death in a family have a contributing role by influencing our eating patterns. We also see an increase in age and gender as factors, as well as an individual's hormonal balance and some medications such as steroids. In the United States particularly, environmental factors also play a significant role. Unfortunately Americans do tend to have a more sedentary lifestyle in a higher consumption of both fast foods and liquids that are higher in calories, as well being less nutritious. There's also an overabundance in a wide variety of fast foods that are inexpensive and readily available and to top it off, our country tends to celebrate just about every major holiday or social event by entertaining with food. As a result, many of these environmental factors combined with our genetics, significantly contribute to obesity and usually make it inevitable. Unfortunately weight loss surgery really can't control the majority of these factors. No matter what type of surgery we actually perform these procedures never change a patient's age or their gender or even their genetics. The one factor that weight loss surgery can truly help control is the quantity of food an individual's capable of consuming. Fortunately by controlling the quantity of food an individual can eat, we can oftentimes help that patient lose substantial weight and correct several of their underlying medical conditions. The benefits from treating obesity are numerous. Typically we see a reduction in mortality rate while improving overall health by reducing some of the underlying medical conditions such as diabetes and high blood pressure. In addition, there are usually significant reduction in healthcare expenditures and a substantial improvement in the patient's overall quality of life. Currently there are many weight loss options that are available to patients. Unfortunately though most of these conventional methods tend to have a very poor long-term success rate with majority of patients regain their weight back within a very short period of time. In fact many patients will actually gain more weight back than what they actually lost. Weight loss surgery on the on the other hand has a considerably higher success rate long term as a result of the permanent change that we cause and one's eating habits. The average patient will tend to lose 60% of their excess weight. They will be able to maintain this long-term. Additionally, many of the patients underlying medical conditions will dramatically improve if not completely resolve. Currently there are many surgical options available for surgery. The most common and popular procedures performed include gastric bypass, sleeve gastrectomy, or the lap-band procedure. I will discuss each one of these individually. The gastric bypass is a very effective operation. There are many advantages to this procedure, one of which is rapid weight loss. On top of that we usually see substantial weight loss in these individuals. With this type of surgery we can use minimally invasive surgical techniques or perform it laparoscopically. We also have a much longer experience in the United States. To date, gastric bypasses still represent the most common operation performed in this country and still represent the gold standard by which all other surgical procedures are compared. Other advantages of the bypass are that less frequent follow up is necessary compared to other procedures like the gastric band. There are also no adjustments that are necessary and there's no implantable medical device. Unfortunately there are some disadvantages. With the gastric bypass we do have to cut and staple parts of the stomach and small intestine and because of this there is a potential for more complications compared to the band or the sleeve. Also with the bypass we are bypassing portions of the digestive tract and this results in less absorption of some essential nutrients and minerals. As a result all bariatric, excuse me, all bypass patients are required to supplement in the postoperative period to prevent these deficiencies. As indicated earlier, the gastric bypass is also non-adjustable. This is a fixed stapled procedure and under most circumstances should be considered non-reversible. On a national level, we also see a slightly higher mortality rate with the bypass compared to the gastric band or sleeve. Fortunately in our practice over the past 15 years we've experienced no mortality from any of these actual operations. The gastric bypass generally is performed laparoscopically using small incisions and inserting these long trocars or cannulas. We then inflate the abdominal cavity with carbon dioxide to create a working space after which we're able to introduce instruments as well as the video camera. This actual operation is performed in two steps. The first part is making a small gastric pouch and separating it from the distal stomach. Once this is accomplished we then go further down the small intestinal tract to what is called the jejunum and divide the intestine here. The distal portion of the jejunum is then brought up and re-attached to the small upper stomach pouch and then reconnected further down line. When a patient eats now, they become quickly full as a result to the small stomach pouch. The food then transports through the intestinal tract and absorption does not actually take place until further down the intestinal tract when the enzymes from the bypass segment are mixed with the food. In essence what this does, is shorten the digestive tract and does not allow as much time to absorb some of the nutrients and calories. In terms of the gastric bypass, this operation actually works by two mechanisms. The first mechanism is by providing the patient with restriction and restriction is provided by creating this very small upper stomach pouch. The second mechanism by which bypass works is by malabsorption. Both the stomach and the first portion of the intestinal tract are bypassed and by doing this we reduce the number of calories that are actually absorbed. Because there is a two mechanism function here, we often see more rapid and more weight loss compared to other procedures like the gastric band. The gastric sleeve is also a very effective operation. This is also considered a stapled operation. There are many advantages to the band, in fact there are many advantages that the band sees in compares into the bypass but also many advantages and comparison to the band. Compared to the bypass, it is a less invasive procedure. Fortunately we see very rapid weight loss and equivalent weight loss compared to the gastric bypass. Just like the bypass, less frequent follow up is necessary compared to the band and there are no adjustments that are necessary or implantable medical device. The gastric sleeve though, also has similar safety characteristics as the gastric band, in that we see a lower mortality risk and malnutrition risk compared to the gastric bypass. This type of procedure can also be performed laparoscopically. Some of the disadvantages include cutting and stapling the stomach. Fortunately we do not have to bypass or manipulate the small intestinal tract and this is a less invasive procedure. The gastric sleeve is a newer procedure on the US market and has been around approximately 7 to 10 years, but as a result of being a newer procedure there is less long-term data compared to the band or the bypass. Like the gastric bypass, it is also non-adjustable and is completely non-reversible as a result of removing the lateral portion of the stomach. During this procedure, like the bypass, we perform it laparoscopically with the five-incision technique. We do utilize a calibrating tube that is advanced through the stomach into the small intestine. And by dividing the stomach along this calibrating tube we're able to create a very small functional stomach. A lateral portion of the stomach is then removed and excised from the patient's body. What the patient is left with is this sleeve shape small stomach pouch. Just like the gastric bypass, the gastric sleeve works by two separate mechanisms. The first mechanism is restriction. We create a small gastric pouch just like we do with the bypass. With the sleeve gastrectomy, there is no malabsorption. There is however a change in the hormone production have a hormone called ghrelin. Ghrelin is a hormone in our body that stimulates hunger and the majority of the ghrelin production is within this portion of stomach that is removed. By removing the lateral portion of the stomach, we will reduce ghrelin levels by more than 50%. As a result patients will see a substantial improvement in the amount of hunger they experience and a reduction of the volume of food they're capable of eating as a result of the restriction. The gastric band is the last procedure we will discuss and there are many advantages to the band. This by far is the least invasive surgical approach that we have available. In this procedure there is no stomach stapling and there's no cutting and there's no re-routing of the intestinal tract. And as a result this makes it a little bit safer in the preoperative period. One of the advantages of the gastric band is the fact that we can adjust the band and customize the level of restriction that a patient is experiencing. On top of that this procedure is 100% reversible and returns a patient back into its normal anatomy if the band is removed. Like the gastric sleeve, we do see a lower mortality rate and malnutrition risk compared to the gastric bypass and with our band patients, we will actually see similar weight loss in the lower weight individuals compared to a gastric bypass. Unfortunately, our larger weight individuals due tend to lose more substantial weight with the gastric bypass or gastric sleeve. Some of the disadvantages of the band are that it is a slower weight loss compared to a bypass or a sleeve and it is crucial that patients follow up on a regular basis so that we maintain an optimal level of restriction. Periodically as the patient loses weight, it will be necessary to adjust the band to maintain the same level of restriction. It is also important to realize that this is meant to be a permanent medical device that remains in the patient for the rest of their life. Should the band be removed, weight gain is usually inevitable. The gastric band is also performed laparoscopically. We also use a five-incision technique just like we do with the other procedures. With this procedure we use a small calibrating tube just like we do with gastric bypass. The band does come disassembled and we're able to insert it through one of our cannulas or trocars. The balloon is then placed in the stomach and inflated to 20 CCs and then once the band is inserted, it is wrapped around the lower border of where the calibrating tube is located. This then creates a very small upper stomach pouch that is segmented from the distal stomach. The band is then attached to a tubing system which is brought out to the outside. Once on the outside, the tubing is connected to a port system which is subsequently placed underneath the skin and underneath the fat. The port system will actually be sutured to the muscle so that it does not move or shift. Periodically the patient will come in and receive adjustments through this port and by adding fluid to the port we can change the inner diameter of the band. Typically patients will follow up every 4 to 6 weeks during the first year of having their band. This allows an optimal level of restriction for the patient to lose adequate weight. Band adjustments are typically done in the clinic these are very safe and simple to perform and generally take no longer than 10 to 15 seconds. Most patients have very little if any discomfort associated with the procedure. Typically we are able to identify the port by filling the outline and then we can use a standard needle and syringe to access the port. We then add fluid to the tubing system which subsequently changes the inner diameter of the actual band. The fluid that is typically used is saline. Saline is very safe if it did happen to leak out of the band into the subcutaneous tissue or the abdominal cavity. As the band is adjusted, what happens then is as a patient eats a meal, it is retained in the upper pouch and fills it up more quickly and stays there for a longer period of time. As a result, patients are able to eat less and maintain a better level of hunger control over a longer period of time. Unfortunately, the band only works by one mechanism and that mechanism is restriction. We provide restriction by changing the inner diameter of the band as can be seen in this photo, an unfilled band has a substantial larger opening compared to a band having several adjustments. As a better reference, a band placed around the upper stomach when it is not filled has very little restriction and a patient is still capable of gaining weight. As several adjustments are performed, the inner diameter or stoma changes to decrease the outlet size. Now as a patient eats it fills up the upper pouch much quicker and stays there for a longer period of time. As indicated, the gastric band really works by only one mechanism, which is restricting the volume of food that a patient is capable of eating. With this particular procedure there is no malabsorption as well as no change in the hormonal levels of ghrelin. All of these operations have the potential to allow a patient to lose a substantial amount of weight. All of these procedures however do come with certain risk. Overall, the risk of undergoing one of these surgeries is very low and very comparable to removing a gallbladder in an obese individual. Unfortunately, obese patients due carry a higher risk because of their underlying medical conditions. As a result that there are higher risk of undergoing any type of general surgical procedure. When looking at the different complications that can occur, there's a broad range of similarity between all of the procedures. There's an increased risk of anesthesia, as well as pneumonia, blood clots and wound infections. With these surgeries also comes the possibility of obstruction either due to swelling right after surgery and inappropriate eating or in the late postoperative period eating incorrectly. Additionally, all these procedures rely on decreasing the volume or increasing the level of restriction of the stomach. Significant overeating over an extended period of time can result in enlargement of the pouch which typically will lead to weight gain over time. Some additional complications seen with the staple procedures is the possibility of a leak or a post-operative nausea. These risks are low but can occur and need to be monitored in the postoperative period. Other complications that we can see with bypasses are ulcerations can occur where the connections are made. Because of the malabsorptive component we can also see deficiencies in vitamins and minerals and again, it's very important that all bypass patients take supplements in the postoperative period. Another condition can also occur with bypasses. It's called dumping syndrome and this results from ingestion of a large concentration of sugar. This typically causes a host of symptoms which include nausea, vomiting, cramping, a fast heart rate and general feeling of being very uncomfortable. Typically dumping syndrome will occur with very concentrated levels of sugar such as found in sweets and soft drinks. Complications that are very unique to the band are due to the mechanical nature of the band. This includes slippage or migration of the band on the stomach. This is typically due to chronic vomiting from a patient being overly tight. Other complications would include band erosion where the band physically erodes into the lumen of the stomach, as well as other complications like a band malfunction from a leak or break in the catheter system. Sometimes we can see complications due to the port where the port flips and we're unable to access it or a leak in the catheter system. Again these procedures are very safe as a whole and are comparable in risking complications to removing a gall bladder in an obese individual. Weight loss after one of these procedures is usually substantial. Good weight loss with the band is typically between 1 to 2 pounds on a weekly basis when the band is well-adjusted. This typically leads to anywhere between 4 to 6 pounds over a monthly basis. It is important to realize that this type of weight loss is usually only achieved once several adjustments have occurred. In comparison, the gastric bypass and sleeve typically lose around half a pound to a pound of weight per day for the first couple of months. After which it does slow down somewhat. Typical bypass and sleeve patients achieve somewhere around 70% excess weight loss by 10 to 12 months after surgery. Unfortunately in banded patients it could take as long as 2 to 3 years to achieve this level of weight loss. As with all bariatric patients they are able to eat most solid foods. There are some exceptions, real thick breads and real dry thick meats can be more difficult especially for banded patients. It is paramount that patients who undergo weight loss surgery change their eating habits. It's important that they learn to take much smaller bites and more thoroughly chew their food, in addition to eating much slower. We do instruct and train our patients how to comfortably eat a small select solid meal. Solid foods work best with any of our bariatric procedures in comparison to liquids. Liquids have very little restriction with any of these procedures. Now there is no limitation to liquids, but we do instruct our patients not to drink during meals in order to prevent any type of wash out of the food or liquefaction of the food. Obviously we never recommend high calorie liquids as none of these procedures really control the amount of liquids a patient can consume and it's very important that patients long-term avoid any carbonated drinks as these may stretch the pouch and lead to weight gain over time. In our program is also mandatory for all of our patients to follow up with the dietitian for at least the first year so that they can be properly instructed on proper eating habits and monitored closely. Additionally lifelong follow up is required. We expect our patients to follow up at least on a yearly basis after the first two years. Followup obviously it's going to be a little bit more frequent during the first two years when the patient is actively losing weight. With substantial weight loss comes substantial benefits. Oftentimes we see significant improvement in overall healthcare with a reduction in diabetes, high blood pressure, asthma, reflux, and high cholesterol levels. We also see an improvement or resolution of sleep apnea. We also see improvement in fertility and pregnancy, a reduction in depression and oftentimes reduction in certain types of cancer such as uterine, breast, and colon cancer. Many patients can be candidates for surgery. Unfortunately most of this does depend on requirements by the insurance company. Most insurance companies are going to require that a patient be at least 18 years of age, with a minimum body mass index of 40 or higher. For those individuals with body mass indexes between 35 and 40, they must also document that they have a significant underlying medical condition as mentioned previously such as diabetes and high blood pressure. Most insurance companies would also like to see some type of previous attempt at non-surgical weight loss where that the patient has failed non-surgical weight loss. It is very important that we review your insurance policy because every insurance is somewhat different and have different requirements as far as who can be approved for surgery. The majority of insurances nowadays do require somewhere between three to six consecutive months of weight management with a dietitian. Additionally a psychological evaluation is generally required and some type of documentation supporting that the individual has been morbidly obese for over two years. Insurances also require documentation to substantiate the patient's underlying medical conditions. In general we would also like patients to ask their primary care physician for a letter of reference. But this is not mandatory in actually getting approved. It just helps us expedite the overall process. As far as getting approved for surgery, the process is very straightforward and can generally be broken down into three simple steps. The first step is filling out our online registration and insurance form. Doing this allows us to verify with your insurance company that you have weight loss benefits and to find out specifically what's your insurance's requirements are to be approved. Typically the first step only takes about 10 to 15 minutes and can be started today after you finish this presentation. The online registration forms can be found on the homepage underneath the patient form and then clicking on the bariatric surgery forms. Again this typically takes about 10 or 15 minutes and once this is done, we can initiate the approval process. The second step generally is very quick also. During this step we would like you to obtain your medical records, documenting your underlying medical conditions and any weight loss programs that you have participated in the past. It is also very important that we substantiate that you have been overweight or morbidly obese for a period longer than two years. Usually to obtain these medical records, it takes one to two weeks. Therefore really these first two steps can be accomplished within a very short period of time. Generally the third step takes the longest and that is participating in some type of weight management program with a dietitian. Not all insurances require the supervised weight management, but if your insurance does it's probably going to take somewhere between three to six months to accomplish this. Once all these steps are accomplished, its very simple to get patient's approved for surgery. It generally takes less than two weeks to have a response from your insurance company. We do request that patients try to be patient. In some cases it does take more time to obtain the proper documentation especially for those individuals who require some type of weight management program. Even when all the documentation has been provided to the insurance companies, occasionally we do need to put the patient through the appeals process. Fortunately we have a very experienced insurance team and we are very successful in getting people approved for these surgeries. Unfortunately some patients are going to discover that their policy has an exclusion to weight loss surgery and this is usually dependent upon the patient's employer. Unfortunately, when there is an exclusion to surgery there's very little that we can do from an insurance standpoint. For those patients who have an exclusion or don't specifically meet the insurance requirements there are finance options that are available. We work with several different finance companies such as CareCredit and e-medical loans to help the patient finance these procedures over an extended period of time at a very reasonable rate. Several of these financed companies can also be found on our website under the next step option found on the homepage. It is very important to realize that there is no cure for obesity. Surgery is a tool to help our patients facilitate weight loss and change their lifestyle. Surgery will definitely help patients lose weight, but by no means will make a patient lose weight. As I often tell my patients, unfortunately there is no surgery that will actually counteract poor eating habits. It's absolutely essential that patients learn to make some lifestyle adjustments, not only changing their eating habits but some of their activity level. This along with surgery will result in substantial weight loss results and improvement in the overall patient's health.