Amanda Wilde (Host): If you're struggling with obesity, weight loss surgery may be an option. There are different types of bariatric surgery available, and we'll sort this out today, with Dr. Jorge Almodovar, Bariatric Surgeon at Eisenhower Health. I'm Amanda Wilde, and Dr. Almodovar, it's a pleasure to have you here.

Jorge Almodovar, MD: Hi, Amanda. Thank you for having me here today.

Host: Can you start by describing bariatric surgery? What is the procedure and why do people get the surgery?

Jorge Almodovar, MD: Absolutely. So, bariatric surgery consists of multiple different types of operations that, with the end goal of weight loss. It's typically performed for people who've struggled for extensive periods of time with obesity and may also have comorbidities associated with obesity. These patients are often experiencing significant impacts of obesity on their everyday life.

 They are experiencing issues with their health, with their ability to essentially function, their ability be physically active is limited. Not only that, it can decrease their lifespan. In addition to having to live with other struggles of health such as high blood pressure, sleep apnea, diabetes, reflux disease, and so on.

Host: That's a lot. What does the surgery do?

Jorge Almodovar, MD: So there's essentially two different types of operations and even a combination of the two. So, to begin, there's the restrictive type of surgical operation, which is something like the sleeve gastrectomy, or even, the laparoscopic gastric band. So the procedures are either volume restrictive, or nutrient malabsorptive, or a combination of the two. So the restrictive procedures are procedures that ultimately limit the caloric intake by reducing the stomach's capacity for holding food and that's either by resecting or bypassing the area of the stomach.

These restrictive procedures include the vertical banded gastroplasty, the laparoscopic adjustable gastric band, intragastric balloons, and the vertical sleeve gastrectomy. The majority of these procedures aren't performed as frequently as they used to be. However, the vertical sleeve gastrectomy has now taken off and has been the most performed operation in the world for bariatric surgery.

Greater than 60 percent of all bariatric surgery is the vertical sleeve gastrectomy. And what it is essentially a procedure that excises or resects a large portion of what's called the greater curvature of the stomach. And so in turn, the reservoir capacity of the stomach is significantly decreased and patients aren't able to eat as much.

Not only that, patients will essentially have a change in their appetite because there are hormonal changes that occur as a result of a sleeve gastrectomy. The stomach holds multiple cells that create a hormone called ghrelin. And ghrelin is the hormone that tells the patient's body to keep eating, even after they've already completed their meal.

And so after this type of surgery, patients one, aren't able to eat as much because the tank is smaller. But two, they no longer have the urge to eat as much, because of the hormonal changes.

Then there's the malabsorptive procedures. And these procedures are procedures that essentially bypass the functional small intestine. And so the malabsorptive procedures decrease the body's nutrient absorption by shortening the absorption length of the functional small intestine that is in contact with food. These include procedures such as the jejunal ileal bypass and the biliopancreatic diversion procedure. Then lastly, there's a combination of the restrictive and malabsorptive type of surgical procedures, and these consist of the Roux en Y gastric bypass, the duodenal switch, and the single anastomosis duodenal ileal bypass with a sleeve gastrectomy.

And so these type of procedures combine the restrictive process that limits the capacity of the stomach to hold food, but it also bypasses a good portion of the small intestine. And so patients aren't absorbing the calories and the nutrients and ultimately end up in a negative caloric balance.

Host: Mm hmm.

Jorge Almodovar, MD: Which leads to weight loss.

Host: And how safe are the types of procedures you've been describing?

Jorge Almodovar, MD: So today they're extremely safe. The complication and mortality rates are less than 1%. This is much different than what we experienced in the early nineties, when there were complication mortality rates greater than 11 and greater than 1 percent mortality rate.

Host: What is the success rate of the bariatric surgeries you do, and how do you rate success?

Jorge Almodovar, MD: So I don't have an exact number as to what is considered to be successful. But, the way in which I rate the success is, obviously, number one, the percent of body weight that the patients lose. With the vertical sleeve gastrectomy; patients can be expected to lose up to 60 percent of weight or 30 percent of total body weight loss.

And so the way in which I rate it is on how the patient feels, how they are doing postoperatively in regards to their other health concerns. Sometimes patients have high blood pressure issues, such as hypertension or diabetes, and if they're able to decrease the dosing or the quantity of medication that they take, then that's a win in that regard.

But, the biggest win is patients' lifestyle changes. People are able to be more functioning. They're able to be more active and in turn, they're able to lose more weight because they're able to exercise more. People experience improvements in their joint function. They no longer have to carry excess weight that is putting an undue amount of stress on their joints.

And so, that has a lasting effect on not only their ability to interact with their family, with their children, if they have children, or just even take an everyday walk and exercise.

Host: So do you see changes in exercise and other lifestyle, like, the eating patterns must change, because as you said, your stomach just, you can't take as much in, or you're not absorbing as much anyway.

Jorge Almodovar, MD: No, undoubtedly. So, you know, patients are going to lack the longing to want to eat an excessive amount. They will have early satiety, meaning they'll get full a lot quicker. And as a result, they're going to end up in a negative caloric balance, which leads them to the weight loss. And ultimately, an improvement in the other comorbidities associated with being obese.

Host: Well, it almost sounds like a little bit of a magic potion. I mean, getting the surgery could change everything about your lifestyle, and it certainly brings down your risks of other diseases. So who is a good candidate for bariatric weight loss surgery?

Jorge Almodovar, MD: So, as I had previously alluded, patients that have struggled with obesity for several years. But the National Institute of Health specifies a little better, as does the CMS, the Center for Medicare and Medicaid Services and what is essentially necessary or what is required is for patients to have a BMI of 40 or a BMI of 35 with obesity related comorbidities.

And these can go hand in hand with what I had mentioned earlier. They can be from hyperlipidemia. Patients with elevated cholesterol, elevated triglycerol levels, high blood pressure. You know, these patients often have uncontrollable hypertension and are often on multiple medications.

Not only that, diabetes. Patients can often get cured from diabetes if they lose sufficient weight. And that is type 2 diabetes to be more specific, and sleep apnea. Patients are able to sleep better because they're no longer carrying the excess weight on their neck, which is resulting in decreased oxygen intake while they're sleeping.

And so, ultimately, they're sleeping better, and when patients are sleeping better, they have better quality of life and a longer life expectancy.

Host: There are so many upsides to the surgery for people who qualify. Um, from the surgeon's perspective of weight loss, is there anything else you'd like to add for people considering this surgery?

Jorge Almodovar, MD: Well, it's a, uh, life changing procedure. The way in which I like to explain to patients about the surgery is that it's not a cheating tool. It's more of a head start. And so, patients need to essentially be disciplined and ready to have the surgery. There's a long checklist of things that patients need to complete in order to have the operation.

And so, they need to be in a right mental state and they actually have to be in a period in which you're losing weight because if not, insurances won't approve the operation. And so, when people see me, it's anywhere between a six month to one year process to get onto the operating room table.

Host: So, it isn't a magic bullet, and you do have to be ready and committed.

Jorge Almodovar, MD: Absolutely. Patients have to lose a certain amount of weight in order to be approved. They need to see a registered dietitian consecutively for anywhere between three to six months. We need to have documented attempted weight loss for these patients. They need to be seen by a behavioral health specialist to ensure that these patients are mentally fit to potentially comply with all the requirements pre and post operatively, because it is essentially a lifelong journey.

Host: Doctor, thank you so much for this insightful, in depth information on bariatric surgery and who can benefit.

Jorge Almodovar, MD: You are very welcome.

Host: That was Dr. Jorge Almodovar, Bariatric Surgeon at Eisenhower Health. For more information, please call the Eisenhower Bariatric Center at 760-834-3796. Or visit our website, EisenhowerHealth.org/Bariatric. If you found this podcast helpful, be sure to share it with friends and family, and check out the entire podcast library for topics of interest to you.

Thanks for listening to Living Well with Eisenhower Health. Health care as it should be.