Transcription:
Bariatric Surgery

Amanda Wilde (Host): Bariatric surgery is a powerful tool to gain control of losing weight. And these days it's more popular than ever. The decision to have bariatric surgery is always made in consult with a specialist. And today we're talking with specialist, Dr. Jeffrey DeSimone, Bariatric Surgeon at Crouse Medical Practice.

Welcome to Crouse HealthCast, a podcast brought to you by Crouse Health. Dr. DeSimone, welcome to the podcast.

Jeffrey DeSimone, MD (Guest): Thank you.

Host: How did you get into this field? And how long have you been performing bariatric surgery?

Dr. DeSimone: That's a very interesting question. So initially I was asked by a CEO of a hospital, if I would be interested in developing a bariatric surgery program. And as you alluded to, bariatric surgery refers to weight loss surgery. And that was approximately 18 years ago. And, initially I was a little skeptical about getting involved in weight loss surgery, but as I investigated it more and investigated how wonderful it was for a number of patients who had no other option, but to turn to surgery, to help them lose weight and improve their health; I found that it's a very rewarding field to be in. So I've been doing weight-loss surgery for about 18 years now and been a surgeon for about 32 overall.

Host: So you must've seen some advances in bariatric surgery in these last 18 years, would you say?

Dr. DeSimone: Absolutely. As they say, this isn't your father's bariatric surgery, if you will. Bariatric surgery, has been around in one form or another since approximately 1954. And a lot of people don't really understand that. It seems like it's a relatively new devlopment just in this century, but that's not really true.

However, the surgeries that are performed are considerably different than they were 68 years ago. They're definitely a lot different than they were back then. So yes, it has changed considerably.

Host: What types of bariatric surgery do you do?

Dr. DeSimone: So right now, what we do at Crouse Hospital is what is typically done across the nation. The most common bariatric surgery across the United States is a procedure known as a sleeve gastrectomy. And briefly what a sleeve gastrectomy is essentially making the stomach considerably smaller, taking the stomach from approximately water bottle size and making it a long slender stomach.

So you restrict the size of the stomach that in the United States is the most common surgical procedure done for weight loss. The second most common procedure done for weight loss is one that's a little older, it's been around a little longer, and that's known as the gastric bypass and real briefly in a gastric bypass, what we essentially do is we make a very small pouch out of the stomach, probably take about 10% of the stomach and make it into a very small reservoir and then bypass the remainder of the stomach and about six or seven feet of small intestine. So it helps patients lose weight by both restricting what they can eat and decreasing the absorption of some of the foods they do eat.

Those are far and away the two most common operations and nationwide they account for approximately 93% of all surgeries done. And those are also the most common procedures we do here at Crouse.

Host: How do you decide which of those procedures a patient should do?

Dr. DeSimone: Well, I think there's a couple of different factors that we look at. Certainly, I try to educate my patients about the differences between the two surgeries and then clearly let them decide, which is most acceptable to them. So, I usually don't like to make the decision for the patients. I have some patients who would like to abdicate that authority to me, but I try to convince them that it has to be the right fit for them.

Having said that, I do also advise them that there are conditions I feel are better treated with one surgery than the other. For instance, I think if a patient has type two diabetes and it's been relatively recent onset, certainly less than 10 years onset, they have a very good chance of being able to completely resolve their diabetes with a gastric bypass.

The sleeve gastrectomy certainly helps diabetes, but the gastric bypass might give a patient a 60 to 90% chance of actually resolving their diabetes. So that's a big factor. other factors have to do with prior surgeries that the patients have had. And there is a if you will, a risk aversion by some patients. And they sometimes find that the bypass is a little scarier to them, if we show them the schematic diagrams, they feel they can't really wrap their head around that operation and understand it as well, and feel a little more comfortable with the sleeve sometimes. So those are the main factors. Diabetes, reflux, which is bad heartburn and the patient's preference.

Host: So besides losing weight, there are some other benefits of bariatric surgery, like you were saying, could resolve diabetes.

Dr. DeSimone: Absolutely. What we've learned over the last 30 years or so, is that unfortunately, there's a number of disease processes that are directly related to being significantly overweight. Diabetes is one of the predominant ones. It's about seven and a half times as likely to occur in someone who is morbidly obese than someone who is not. High blood pressure, high cholesterol, of course, all of those are risk factors for heart disease, obstructive sleep apnea, lung diseases, and even a whole host of cancers are more common in patients who are morbidly obese. Reversing that morbid obesity, particularly when it's done as early as possible, changes those, what we call comorbid conditions or helps decrease the likelihood of developing diabetes, hypertension, even some cancers.

Host: Is this a surgery where you're cutting into someone or is it performed robotically?

Dr. DeSimone: So the surgery initially, obviously years ago, was performed through a large abdominal incision. As time went on, different innovators in surgery have been able to first perform the surgery, minimally invasively with what we call laparoscopic surgery. And now in this century, probably over the last four or five years due to the advances in what's known as robotic surgery. Here at Crouse, we perform the majority of our surgeries robotically, which means minimally invasively, small little incisions. And instead of the surgeon actually placing their hands inside the abdominal cavity to achieve what they're trying to do; the surgery is done with long slender instruments that are much less traumatic to the patient.

So, pain is much reduced. And, patients are actually recovering very rapidly from surgery. And we're really on the cusp of doing same day surgery for weight loss, which I think if, my mentor is when I was a resident, 32 years ago, had any clue that we would be doing weight loss surgery and sending patients home the same day, they would not have believed that that was possible, I don't think.

Host: Like couldn't foresee that even happening in our lifetime?

Dr. DeSimone: Correct. So one of the things, when I first started doing surgery, there was no such thing as laparoscopic surgery. Minimally invasive surgery wasn't heard of. And over the course of my professional career, we've gone from large open incisions to smaller incisions with laparoscopic surgery, to now smaller incisions with robotic surgery.

And I foresee the next step being very small single site incisions for some of our operations, where instead of typically I do four or five small incisions to accomplish these operations, I'm predicting in the next five years, some of these operations will be performed with a single incision, less than an inch long.

Host: Wow. That's amazing. So you're really perfecting the surgery and that keeps the recovery time low. I would expect. Is that right?

Dr. DeSimone: Absolutely. Again, we find that recovery is based on a lot of things. If a patient has a great deal of pain, they're not going to want to move very much as you can, imagine. Narcotic painkillers that we give to relieve pain, are wonderful for pain relief, but they have some side effects that may be undesirable like nausea and constipation.

And of course, if you're nauseated, you're not going to want to drink well, which means you need to be in the hospital for intravenous fluids, et cetera. So reducing the pain, reducing the pain medications, allowing patients to become more mobile earlier in the recovery period, really has revolutionized surgery.

Host: So recovery is getting easier and easier. Do people ever need like a follow-up revision surgery after a bariatric surgery?

Dr. DeSimone: Occasionally our patients do. That leads me to something else that I would like to really stress with this. We make a big deal about the surgery and the surgery is a very, very powerful tool to help our patients lose weight. But I like to make sure I remind my patients not to lose sight of the fact that they still have some responsibility to eat mindfully, to be careful about eating foods that are healthy, without too many calories, to avoid the foods that we know are linked towards morbid obesity and to be as active as possible because diet and exercise are still significant aspects of the surgical program. We do recommend following patients every year after their surgery.

Initially for the first year, I like to see them at least every three months, the second year, every six months. And then once a year after that. Those patients who follow up with us more carefully, have better results and better long-term weight loss. If a patient does have problems with weight regain, there can be, not always, but there certainly can be many patients who would benefit from revisional surgery on occasion.

Host: Well, you were just talking about how you follow up. And I was curious, what do you see in the longterm with these patients in terms of the surgery remaining successful throughout life?

Dr. DeSimone: So as I like to tell patients, there's no perfect solution for anything in life and weight loss surgery is no exception to that. However, with the advances that have been made over the last several decades, and if the patients are careful about careful follow-up, are careful about diet and exercise to the best of their ability, we can see results where somewhere above 80% of patients will maintain significant weight loss after surgery. Now, 80% you kind of need to have a reference point. What does that compare to? If patients are able to lose significant amounts of weight with diet and exercise alone, the vast majority of those patients, over 98% of patients will regain weight when they go onto what's called a maintenance diet. By comparison weight loss surgery, as somewhere in the vicinity of 80% success rate with long-term weight loss. So it's considerably better than the other options. And when patients are heavy enough, when they reach what we call a body mass index of 40, which for the average patient means they're approximately a hundred pounds overweight; to be able to keep the significant amount of weight like that off, the surgery is, definitely more more successful than diet and exercise alone.

Host: And what makes the Crouse Bariatric Program a particularly good choice for surgery? For me, I would say the opportunity to access your expertise and experience, but what do you think?

Dr. DeSimone: Well, I certainly appreciate that. And, I do say that we have three surgeons currently in our practice, with a combined over 54 years of experience doing weight loss surgery. All of our doctors have at least 15 years of experience doing this. We all use the most current techniques including, we're well-schooled in open surgery, but, of course in laparoscopic and robotic surgeries as well, we all do these newer techniques.

But I think, we have an excellent team, whether we're talking about our nurses on the floor who are very familiar with our patients, because we do a high volume of cases and it means that the nurses have a good experience recognizing problems should they occur early on so we can intervene and avoid those as much as possible helping patients, improve throughout the course of their hospitalization.

We have good staff in the office, nurse practitioners, physician assistants, dieticians, registered dieticians and psychologists, and a complete comprehensive program of people. And again, I think our biggest benefit is the post-operative care that's rendered by all of these people, to our patients.

We have good surgeons who are able to do the procedure and then excellent follow-up providers who can lead our patients through their recovery phase.

Host: Sounds like a blue ribbon team. Thank you for making bariatric surgery a safe and medically supported choice for those, for whom it is an option.

Dr. DeSimone: Well thank you.

Host: And thank you for listening to Crouse HealthCast. To learn more, visit crouse.org/weightloss. If you found this podcast helpful, please do share it on social media. This is Crouse HealthCast, a podcast brought to you by Crouse health. I'm Amanda Wilde. Be well,