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Bill Klaproth: There are many questions, fears and assumptions when it comes to bariatric weight loss surgery and here to clear the confusion is Dr. Bobby Bhasker-Rao, known in the community as Dr. Bobby. He is a bariatric and general surgery specialist at Eisenhower Medical Center. Thanks for your time. Besides the obvious external benefits of weight loss and looking better, what are some of the other medical and health benefits of bariatric surgery?

Dr. Bobby D. Bhasker-Rao, MD: The medical benefits are significant as you may or may not know. Obesity actually leads to several comorbidities and diseases or medical issues that arise as a result of gaining all that weight. We see about 30 of these, but some of the most talked about ones are diabetes, about a 400% increase in type 2 diabetes, hypertension, very commonly associated with obesity, and hypercholesterolemia, all of these three put together actually make up a metabolic syndrome that a lot of people talk about, which is essentially increasing your risk of atherosclerosis, clogging up of the arteries. That also then leads to heart attack or a stroke. In addition to that, there are also others like obstructive sleep apnea, pulmonary embolism, cancer – cancer as well is much more prevalent among obese patients – liver disease, orthopedic issues such as our backs, our knees, our ankles. These joints were not created to carry these large amounts of weight. As you can imagine, they deteriorate prematurely. There's a whole list of problems that arise as a result of the weight gain. What obesity surgery can do is get rid of a lot of these issues. With some of these problems, for example, diabetes, you can see that disappear in almost 90% of the patients. You'll see either a complete resolution or a significant improvement in their type 2 diabetes.

Bill: There are many benefits besides looking better. You are also mentioning joints. You were just featured in Healthy Living Magazine along with Dr. Desantis about bariatric surgery being helpful for patients needing a joint replacement. Can you briefly tell us about that?

Dr. Bhasker: A lot of times, there's large amounts of weight when patients go to their orthopedic surgeons. It’s a challenge for the orthopedic surgeons to replace a knee or fix a knee because the weight does not help these heal properly, so a lot of times, they will send these patients over to me first, help these patients lose a significant amount of weight and it definitely makes a difference in terms of their success rate with their orthopedic surgical outcomes. They just heal better and even the entire surgical process is much easier.

Bill: You could also say lose the weight and save the knee or the hip because once that weight is off, the pain associated with that extra weight in the joint can go away. Is that right?

Dr. Bhasker: Yes. You're taking the weight off, which is essentially causing a lot of the pressure, but sometimes it may not necessarily be related to the weight, but in order to get that knee fixed, you might want to lose some weight so that it does actually respond appropriately.

Bill: Even with the many benefits, some patients perceive bariatric surgery as dangerous when in fact the procedure has low complication rates. Can you talk about some of the common fears associated with bariatric surgery?

Dr. Bhasker: I think one of the biggest fears is based on what's happened in the past where surgeons were not really well trained. The ones that did it way back when in the 80s or 90s, they weren’t really appropriately trained and bariatric surgery was also new back then. They did not really know how to manage certain complications but things have really changed over time. Mortality rates now with bariatric surgery is safer than even a gallbladder operation. It's one of the safest procedures out there because of all the improvements and changes that have occurred over time. You have better-trained surgeons, better instrumentation, and our knowledge of managing complications has significantly improved. That's one of the biggest myths that if I have surgery, I'd have a major complication or die from it. Even the major complications that people think about are also significantly decreased over these past several years with improvement in instrumentation and training, much better than what it used to be.

Bill: Who is a good candidate for bariatric weight loss surgery?

Dr. Bhasker: We basically go by the NIH guidelines, the National Institute of Health, and these are old guidelines that are still the one thing followed today and it might change in the near future, but as of now, that’s what we have. What it is is if a patient has a BMI of 40, and a BMI is basically their weight in kilograms divided by their height in meters squared, you plug these numbers in and if their BMI is 40 and above, they automatically qualify for surgery. To translate that in terms of how much excess weight that is, if a patient is 100 over what they're supposed to weigh, that will typically put them around a BMI of 400. The other equation is a lower BMI of 35. If a patient has a BMI of 35, which is roughly 75 pounds over their ideal body weight, in addition to that, they also suffer from one of these comorbid conditions, such as diabetes, hypertension or sleep apnea, they would qualify as well. To simplify it, you have to be at least 100 pounds over with or without any comorbidities or have a BMI of at least 35, which is 75 pounds over, with at least one of these major comorbidities.

Bill: That’s very good to know. Can you talk about the advancements then in the procedure when someone elects to have this done using the Da Vinci minimally invasive method and the benefits of that?

Dr. Bhasker: There's definitely been a significant improvement in technology, even going from open, which is big midline incision and the surgeon puts his hand in there and does the entire procedure, versus minimally invasive surgery where you actually make tiny incisions, put a camera through one and instrumentations through the other and you do the entire procedure with this type of a minimally invasive technique. Laparoscopy is a big deal now. That's how a lot of these procedures are being done, but what's happened over the last four to five years is robotics has been introduced to surgery and me being one of the first guys to adapt it in the field of bariatric surgery, what we're seeing is much more precise and safer surgery, which has enabled patients to experience less pain and actually leaves the hospital sooner, they're typically in the hospital overnight, they're also able to get back to their regular activities sooner than what it used to be like prior to robotics.

Bill: That’s such good news. Can you very quickly tell us about the four options then for bariatric surgery today?

Dr. Bhasker: The most popular option and the gold standard, or what all the other procedures are compared to, has been around for the last 50 years and that’s the Roux-En-Y gastric bypass. That’s where we actually divide the stomach and create a much smaller stomach pouch out of the original stomach and we reroute intestines in such a way that we're bypassing the old stomach. These patients end up with a much smaller gastric pouch, which enables them to eat much smaller quantities of food, therefore less energy in and more energy expenditure and enable them to lose weight evenly from head to toe. You have the sleeve gastrectomy, which is gaining a lot more popularity because it's less of an operation than a gastric bypass and you could potentially gain equivalent outcomes. This is where we actually divide the stomach longitudinally so they end up with a small banana-shaped stomach and that's pretty much all you do with that operation. It enables you to lose weight just as efficiently. One thing that I did not mention about both these operations is there's also these endocrine/metabolic changes that are undergone in the body, which is what gives them all the benefits of these operations, which is getting rid of diabetes, getting rid of hypertension, getting rid of sleep apnea and such.

The third option is a lap band, which is slowly falling out of phase because we’re not seeing as effective results with it, but there is a group population that will benefit significantly from it. The lap band is basically a device placed around the upper portion of the stomach that creates a restriction and that restriction is adjustable. You're able to restrict how many calories go in and therefore less calories in, more energy expenditure and you lose weight by putting in less food. With this procedure, there are no metabolic or endocrine advantages. The last but not least is a modified version of an older duodel's procedure and it's complex to discuss that since insurance companies are not quite on board with it yet. We don't have to discuss it in that detail, but I definitely discuss it at my seminars when I speak twice a month.

Bill: That’s great information and thank you for sharing that with us. If you want to learn more, just call 760-778-5220 or visit eisenhowerhealth.org/bariatric. That’s eisenhowerhealth.org/bariatric where you can take an online assessment to see if bariatric surgery might be the right choice for you. This is Living Well with Eisenhower Health. I'm Bill Klaproth. Thanks for listening.