Melanie Cole, MS (Host): Welcome to Bryan Health Podcast. I'm Melanie Cole. And today we're discussing weight loss surgical options. There are so many out there today and more tools in the toolbox for doctors like my guest today is Dr. Anthony Tabatabai. He's a General Surgeon with a specialty in Bariatric and Weight Loss Surgery at Bryan Bariatrics and Surgical Associates.

Dr. Tabatabai, it's a pleasure to have you join us. I'd like you to start by kind of setting this up for us. What is defined as obese and what other comorbid conditions can arise from obesity? What other diseases does it contribute to?

Anthony Tabatabai, DO: Thanks, Melanie. Yeah, this is a huge topic, as far as obesity and what we consider patients weight and height as a conglomerate to body mass index. And what we're seeing is basically patients with a body mass index of 35 and above with a comorbid condition such as hypertension, sleep apnea, diabetes, these types of conditions, start arising as weight gets put on.

So, any patient that has a BMI above 35, even 30 now is considered obese. But as far as a surgical arm, we look at patients with the BMIs of 35 and above with a comorbidity, or BMI's of 40 and above without any comorbidity necessary. But really this is an option for patients to really tackle this epidemic of obesity and allow them some help to get this weight off.

Host: Well, it really is, as I said in the beginning, another tool in the toolbox of doctors such as yourself. So help us to understand the options for weight loss, including surgery. If you'd like to start with conservative management first, that would be great, but I'd like to get into the types of bariatric surgery that are available now and the types that you perform.

Anthony Tabatabai, DO: I think overall, the first step is really meeting with us and that doesn't mean you're going to surgery or anything like that. We really get you into our program and that's the process. First we meet, we discuss what options you've done in the past or what you've tried and see what we can do as far as a program to help you.

That might be a medication to help with some weight loss. That might be some lifestyle changes with exercise. And then also, obviously, what you're eating. We look at high protein and low carbohydrate diets as really the mainstay in patients, in our program. And that process, as you meet with us, we can kind of help you through our program and get the best option.

 And then going further, obviously as a surgeon, being able to offer that wing too, as far as surgery to help with weight loss is a huge option. And, based on the data that we have and the literature, it's the best option to get this weight off. And when I see patients, we're not talking about 10 or 15 pounds to get off.

I mean, some of these patients need to lose 100, 100 plus, 200 pounds. So that's where the surgery is really the game changer in that regard. As far as our program, we offer a wide variety of surgical options. These include, the sleeve gastrectomy, the Roux en Y gastric bypass, the biliopancreatic diversion with duodenal switch and the single anastomosis duodenal ileostomy with sleeve gastrectomy. So these are four of our mainstay options that can help patients with obesity and really getting this weight off.

Host: Doctor, in the past bunch of years, we've seen surgical options evolve and change. It's really an exciting time in your field. So tell us now, with surgeries we used to do that we don't do anymore, there are some that you don't do that people have heard about.

Anthony Tabatabai, DO: There's some very old school surgeries and this was just how again, medicine evolves and how we're helping try and take care of patients and move the needle with this issue of obesity, but, vertical banded gastroplasties, laparoscopic gastric banding is still done, but very, very little, jejunal ileal bypasses, all these types of surgeries that we really don't do anymore. I'd say the mainstay right now that is the most popular is the sleeve gastrectomy, and I'll touch on that, as a start. That's basically taking out 85 percent of the stomach and removing it, and we use a tube that's placed down into the esophagus and into the stomach, and I kind of follow that tube as a guide to make everybody's sleeve the same size.

And we make sure we get the top part of the stomach, the fundus, out, and that's where a lot of hormone receptors are for appetite. And a lot of these medications that you're seeing all over the news are really affecting that area of the stomach, too. So when we take that all out, patients really feel full very quickly.

They'll probably eat about four to five ounces and feel satisfied. That's where you get that restrictive caloric intake, so patients are probably taking in about 600 to 900 calories a day, but they don't feel like they're starving themselves. They feel full and they move on, and they also dampen their appetite too, as far as the sleeve gastrectomy goes. So, it's a good option. As far as weight loss expected with that type of surgery; you're looking at 60 to 70 percent of your excess body weight, or about 20 to 30 percent of actual weight coming off with that surgery.

Host: That is just amazing. Now speak about patient selection, because as you said, just because someone comes in doesn't mean they're going in for surgery, but there are some parameters and criteria that they have to fulfill, including mental health counseling and that sort of thing. Please tell us a little bit about patient selection and what's involved in getting approved for surgery.

Anthony Tabatabai, DO: The biggest thing is that first consultation with us and we kind of go through all of the elements. That includes visits with our medical weight loss team, like a nurse practitioner or our PAs that work with us, and that's kind of looking at the overall program and how you're doing through the process.

 Exercise physiology, we want people to have opportunities even if they don't go to a gym and things like that to, have ideas and help with some exercise component. Our dieticians are very important as far as again, high protein, low carbohydrate diet and making sure we're on the same page as far as being successful with the diet aspect.

And then we do have patients see psychologists just to make sure that we don't have any underlying depression or other issues that could be causing detriments to the patient long term, especially after bariatric surgery. And then sometimes we make sure the family doctors and pulmonologists making sure the patient's ready for surgery itself.

That's kind of the process. That process takes about three to six months usually, to get through. And all that time we're working towards, towards surgery.

Host: And during that time, what do you want them to do in advance of surgery so they're going through the process of getting approved? Should they be trying to lose weight? Are they, are they keeping a journal? You mentioned exercise. What do you want them to do in that, in that waiting time?

Anthony Tabatabai, DO: From my standpoint, taking care of patients with this amount of excess weight on, there are patients that adopt these kind of parameters and lose weight, and that's awesome to see. I've had patients lose 50, 60 pounds prior to surgery, which is a great jumpstart for us. Other patients are doing exactly what we're saying, and the weight's not budging, and that's why this is a metabolic problem. This isn't just eat less and exercise more. Once you get this type of weight on, your body metabolically is kind of scrambled, and that's why it's so difficult for these patients to lose weight.

Whereas people out there are always just like eat less and exercise, and it just does not work like that for these patients. So, I don't necessarily make a patient lose an amount of weight. I'm happy if they do. That's great for them. We're already hitting the ground running. But, there's no certain number that a patient has to lose prior to surgery.

Host: Then let's speak about surgery and post op. What happens after the surgery? What is life like for them? What is recovery like for them? Can they eat? Is it liquid diet? Is there support groups, nutrients, supplements? Speak about life after.

Anthony Tabatabai, DO: That's the nice part about being part of a center of excellence and a program. We help with this process throughout. We follow patients at two weeks, five weeks, three months, six months, nine months, a year, 18 months and then yearly after that. We like to see patients and make sure things are going okay from the surgery.

As far as diet advancement, there's a preoperative diet that we have patients on prior to surgery for about 2 weeks. And then after surgery, patients are usually on a full liquid diet for two weeks, and then we advance to a type of soft diet for about three weeks. And at five weeks after surgery, we're back to regular food.

 We're going to eat a lot less based on any of the surgeries that we do. And I can touch on a few more surgery options as well, in a minute, but, that whole process, is the same for everyone, no matter what surgery you get. The surgery's done minimally invasive in my hands I use the robot and control the instruments and we do this surgery and people stay overnight and usually are home the next day within 24 hours.

And again, we have close follow up in our office post operatively as well.

Melanie Cole, MS (Host): What about life once they're done? Can they go to restaurants? Can they go to parties? Is there support groups for their family? Because maybe it's a mother who's cooking for a large family and it's very tough to be going through post operatively this type of surgery and not be able to do what you're feeding your family, attend holidays. What is life like for them that way as far as quality of life?

Anthony Tabatabai, DO: That's a huge component of having support, and obviously we have support groups, and then also, just having family members support patients through this. It, will look different, I mean, as far as servings and stuff, patients that have had bariatric surgery are going to take in a lot less food.

But, the offset of that is, if the patient's lost 200 pounds or 150 pounds and have got their life back, a lot of my patients are ecstatic and okay with that. And they, understand that component of the postoperative phase. I think as far as being a bariatric surgeon, there are still holidays, there are still birthday parties to go to. I tell my patients that you can have a piece of cake, it just might not be two big pieces of cake, I mean, it's going to be a small amount and, that's kind of a luxury kind of thing. In the day to day, it's going to be high protein and low carb and keep that weight off long term, so.

Host: What about supplements? Are they on supplements to make sure that they are getting all the nutrition that they need?

Anthony Tabatabai, DO: Yep, we have patients start on multivitamin, at the bare minimum, and then sometimes we also have some additional vitamin supplementation, especially depending on the type of surgery that they've had. Some of these other surgeries that I'll touch on really quick is, a Roux en Y gastric bypass, which we cookie cutter out part of the stomach and bypass some of the small intestine with two different connections, and that adds a little umph in the weight loss as far as a malabsorptive component where the small intestine isn't allowed to absorb those calories.

So say you take in 300 calories, you might only absorb 200 calories. So they get an added umph in the weight loss. That surgery's been around since the 1960s. We're looking at about 60 to 75 percent of the excess body weight being taken off with that surgery.

 And then you go to another surgery called the biliopancreatic diversion. It's duodenal switch. And that's a kind of combination between a sleeve and a bypass. We make a sleeve, a slender tube for the stomach. We take out the excess and then we bypass the, duodenum, basically the end of the stomach. We connect to the ilium and then re-hook up the small bowel creating a common channel area where the enzymes and the food meet, and that's where your calories are absorbed. And that's a very short common channel. So patients with that surgery tend to be a lot heavier with a BMI greater than 50, but they really need the help with the surgery to get all that weight off.

But they tend to have a little bit more nutrient deficiencies that we have to be monitoring, but again, multivitamins, very helpful. And, we kind of watch these types of vitamin labs, pretty routinely. And then a third, final surgery that is kind of a modified duodenal switch as, people call it, but it's a single anastomosis duodenal ileostomy with sleeve gastrectomy. So if you tease that out, it's a sleeve, but this is a one connection from the sleeve to the small intestine and the common channel or where enzymes and food mix is a little bit longer than the biliopancreatic diversion or duodenal switch.

So we've had really good results with this surgery and with only one connection. That's nice. People like that idea too. This surgery, again, the same as the duodenal switch, 80 to 90 percent of that excess body weight is coming off with this surgery, or 45 to 50 percent of their actual weight loss from the time of surgery.

Host: Dr. Tabatabai, thank you for sharing your expertise. As a final question, I'd like you to speak to the listeners now with your best advice. When people are severely overweight, what should they think about when considering bariatric surgery and when they hear some of the myths and things that other people might say that it's the easy way out or that sort of thing, because I'm sure you've heard that. I'd like you to offer your best advice right now to the people that are considering this type of procedure.

Anthony Tabatabai, DO: As a surgeon and a physician taking care of patients and seeing their journey through this, it's not the easy way out. They are not giving up by doing this. They're actually using a tool that has shown to be the best option for weight loss for a patient that's morbidly obese. I think there's so much stigmatism still that we're fighting, and as you see everybody's different or you wonder, some of these patients that have 150, 200 pounds on them, they're really not eating that much and there's so much variability in people's metabolic system that, that's where it's very difficult for these patients to lose weight.

So I think, as a bariatric surgeon, I just want people to know that this is an option and that by no means do we force surgery on anybody, but I can tell you all of the facts and that this is safe and that we're making it even more safe than it used to be. And I think we're still fighting some of those stigmatisms from the early onset of bariatric surgery back in the day, but we're also fighting an uphill battle here with all the processed foods and things that we're having to deal with, that's really scrambling people's metabolic system.

And that's why we're seeing patients just, the weight just continues to add on for patients, even though they're trying to make good decisions as far as diet and exercise. It's a very difficult process to combat, but right now these surgeries are the number one way to do that.

Host: Thank you so much, Doctor, for joining us and sharing your expertise today. And for more information, please visit bryanhealth.org/bariatrics. And to listen to more podcasts from our experts, you can always visit bryanhealth.org/podcasts. That wraps up this episode of Bryan Health Podcast.

Please remember to subscribe, rate, and review Bryan Health Podcast on Apple Podcasts, Spotify, iHeart, and Pandora. I'm Melanie Cole. Thanks so much for joining us.