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Melanie Cole (Host): Bariatric surgery may be a life-saving option for obese patients who meet the clinical criteria. Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole. Joining me is Dr. Christian Perez. He's a General and Bariatric Surgeon with the Carle Foundation Hospital. Dr. Perez, it's a pleasure to have you with us. As we get into this topic, I just love to talk about bariatrics because what an innovative procedure this is. As we get into this, can you define obesity for us and the other comorbid conditions that can arise from obesity that make it so that somebody would even consider bariatric surgery?

Christian Perez, MD (Guest): Yes, thank you for having me today. I appreciate the opportunity to talk about this important topic that is obesity. Obesity, it's a problem that's really important right now in the United States. It's an epidemic. It has been around for a long time. As we know it, this is all related to the metabolism of the patients. And if I had something to make people conscious about today, they would be about that. Even us as doctors, sometimes we don't really understand the obesity by itself. We sometimes are pretty easy at judging people before because they either eat too, much or they cannot exercise, et cetera, et cetera.

But the reality is like as Dr. Kaplan recently said on a conference, you don't eat and become obese. You eat because you are obese. So just basically want to tell people that this is related to genetics and other multiple factors, including basically our everyday lifestyle, but genetics plays an important role.

I tell my patients all the time, if I give you the same food that you eat and the same activity to somebody else, they may be smaller than you, or they may have higher weight than you. And that's why it's so important to understand that. And that's what we like to help people, because this is not their fault. We have to stop blaming patients for this.

Host: Ooh, so well said, Dr. Perez. Now I'd like you to speak about patient selection because there are quite a few parameters to even be considered for bariatric surgery. So can you speak to those please?

Dr. Perez: So in general, we go by the classic guidelines that basically is a BMI of 40, no matter what comorbid conditions the patient has. And other than that, a BMI of 35 with two or more comorbid conditions, usually that they need to be documented and treated for. Why are these comorbid conditions? Usually is going to be mainly diabetes, hypertension, hyperlipidaemia, obstructive sleep apnea is the other one, issues with arthritis and it changes a little bit, depending on insurance. There's also some new like guidelines for some different populations, like Asians, that they would go as low as 27.5 BMI if they have comorbid conditions. So those are some relatively new changes that have happened.

But overall in general, I would say that that's the case, like BMI of 40 with no comorbid conditions or 35 with two or more comorbid conditions.

Host: What about risk factors and side effects associated with the surgeries? And we're going to get into the types of surgeries that you perform, Doctor. So before we do that, when you are counseling your patients and for other providers listening that are telling their patients hey, I'd like you to speak to a bariatric surgeon, what are some of those things you make sure that they understand about this procedure?

Dr. Perez: So the main things that it's important to know is first of all, I would do a quick check on the patient to make sure they are good candidates overall. On top of meeting the criteria that I just mentioned, we have to make sure that they are not current smokers. We usually try not to operate on those people because it's a pretty high risk factor for complications on people that smoke. That have usually no psychiatric pathology, or if it's something it should be pretty stable and something reasonable. Usually we don't operate on people that have had any eating disorders in the past and stuff like that. And the other stuff we usually try to do our own triage. What would I tell a patient before they get to surgery?

Well, it's definitely a life-changing experience. Yeah, it's gonna be really good for them to lose the weight. They're going to be able to be more mobile. They're going to be healthier. Their life is going to be overall way better, but they do have to understand that they're going to make a big change on the way they eat and the way they do their activities. Otherwise, these procedures sometimes don't work as good.

Host: One thing I've noticed over the years of talking about bariatrics is this is a tool. It is not the be all and end all. It's a tool, just another tool in our toolbox to help with this obesity epidemic, as you said, and then can help as a result, to reduce the amount of diabetes and high blood pressure and heart disease, all of these things together.

What would you like patients to do? And what do you in the clinic, ask them to try and do in advance of surgery? Should they be trying to lose weight? You mentioned smoking cessation and that, that is, a contraindication for the procedure. What else do you ask them to do?

Dr. Perez: I think it's really important that you ask these questions. It's really important for them to be committed to the process, because it's going to take some time. Sometimes depending on insurance, some patients are going to need some supervised weight loss for six months. Sometimes, not all that time is needed, but we do recommend the patients to start working on losing some weight before. This is when I talk to my patients about this is mainly three reasons. One of them is because when they lose weight, they're basically making their surgery easier and safer for us as surgeons. Number two, it's going to give them an idea how they're going to respond to all these things, because even that these surgeries are pretty strong and they work on their metabolism as well as restriction and other pathways; the metabolism is still going to be there.

So, people that usually lose more weight before surgery, they usually respond a little bit better afterwards. There's not a lot of literature written out there, but there's a couple of papers that have shown that. So I tell them, that's going to show them how they're going to respond to surgery and last but not least, which is really important, once they start losing weight, they're basically starting their treatment. So I think that's one of the reasons we do that. They have to be committed to be able to be compliant with their vitamins, because it's really important. They cannot use their vitamins, they can get in trouble with vitamin deficiency, if they're not compliant and basically commitment to the program and taking care of their own selves to be healthier everyday.

Host: So important. And I'd like to discuss that vitamin therapy too. But before we do that, Dr. Perez, what types of bariatric surgery do you perform? Can you just give us a brief overview of what you're doing there at the Carle Foundation Hospital?

Dr. Perez: The main procedures that we're doing here right now at Carle are basically sleeve gastrectomy and gastric bypass. We do a lot of revisions from other procedures. Like, we don't do lap bands anymore. We do revise people that have had issues with their lap bands or people that the lap band is not working anymore. We do some of those revisions. We also do revisions of people that have had sleeves done that unfortunately have developed some reflux that's not treatable with medications and we revise them to bypass also. Those are the main procedures that we do. Those three, sleeve, gastric bypass and revisions. We're looking into get started trying to do some duodenal switch type of procedures, but that's not something that we offer right now at Carle, but definitely we're a Center of Excellence.

So we'll give an assessment of the patients. If we actually truly consider that the best option for the patient is a duodenal switch, we would be happy to refer them to the appropriate channels and the people that are doing these procedures right now. Our goal is eventually getting to do it. But at this point we don't offer duodenal switches.

Host: So I'd like you to speak about support services for after surgery. Can you tell us about some of the quality and lifestyle changes for post-surgical patients? What you're doing there in your clinic to give them that support? You mentioned vitamin therapy. We've heard about transdermal vitamin patches. Is there any of these things that you would like to speak to that gives us a clear picture of how your clinic is run and how you're supporting patients afterward?

Dr. Perez: We usually, see the patients after surgery, pretty closely. We follow them pretty closely. We see them one week after the surgery, and then at five weeks and then usually at periods, at least every three months between all the surgeons, our nurse practitioners and our dietician to make sure we're keep a close eye on the patients.

They have to take their vitamins. We have a support group on Facebook for our bariatric patients, where they can always ask questions. And we have a really experienced, nurse in our clinic Anne Carroll that she's great and she's always willing to answer questions and be available. And then if there's any question or any concerns at all, we make sure we have easy access for our patients to our clinic to be seen as soon as possible and immediately. We're trying to also work more and more with our primary care physicians around the area. We have some of them that are pretty interested on all these medical weight loss management, and stuff like that. So we're trying to talk to them more and get a more organized system to try to work with them, because I think there's a lot of room from our primary care physicians to help us with all this patient management.

Host: Oh, so true. What a great point that you make. There is a lot of room, and this is, as you said, at the very beginning, Dr. Perez such a big issue with the epidemic that we're facing and those comorbid conditions. Tell us about your team because as we're widening that net of providers that are involved in medically supervised weight loss, and really even trainers and exercise physiologists, physical therapists, everybody, dieticians, nutritionists, so many people are involved.

Speak about your team at the Carle Foundation Hospital and how they all work together for this multidisciplinary approach.

Dr. Perez: So we basically have three surgeons including me. We have two nurse practitioners, but we're going up to three pretty soon here. And we have one dietitian at the moment. I think we're, working on getting an extra dietician because we're going to need that if we're planning on doing some of these other, duodenal switch procedures, eventually. We have a couple of nurses, Elisa and Anne that are experts on bariatrics that are also always there to support.

We don't have per se official therapies or anything in our program right now, which would be great. But again, we work closely with some of our primary care physicians at Carle that actually have started their own medical weight loss management programs and they have a pretty comprehensive center.

So we're trying get all those things together. If I had a good vision on time, I think my goal at some point would be to try to create a Metabolic Center for Carle, if at all possible to try to put everybody under the same hat and be able to have something pretty well organized, but that's going to require some work, but we're working on it.

Host: And do you have any final thoughts for referring physicians about the Bariatric Program at the Carle Foundation Hospital, patient selection, anything you'd like as a key takeaway?

Dr. Perez: I just want them to know that we're always here to support. There's a lot of bariatric patients out there that we didn't even necessarily operate it on them here, but we're happy to see any of these patients, even if they have had surgery anywhere else, if they had any concerns or questions, we're always happy to answer those things.

We also want to thank them because we actually rely on them a lot to follow with some of the vitamins and some of the other problems that the patients can develop on these. I want to make sure they understand that bariatric surgery, it's a great tool, as you mentioned. As we know obesity is associated with seven different types of cancer and if we make the patients better and we can help them to lose weight and be in better shape, we are going to decrease also that. So I think it's, a win-win for everybody. So we have to keep working on it. We also have to understand that we are altering the anatomy in these patients and overall these procedures are pretty benign and well-tolerated, but some people do have some issues afterwards, and that's where it's important for everybody to be cognizant of these things that could happen, like, ulcers, internal hernias on the bypasses, chronic reflux on sleeves. And we're here to support with that and work as a team make sure that our patients and the patients even if they got surgery somewhere else, but anybody that needs our help with care for bariatric patients, we're happy to help any time.

Host: Thank you so much, Dr. Perez, what an informative podcast. Thank you so much for joining us. And for more information, and to get connected with one of our providers, please visit carle.org or for a listing of Carle providers and to view Carle sponsored educational activities, you can always visit our website at carleconnect.com.

That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole.