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Prakash Chandran: According to the World Health Organization, the worldwide prevalence of obesity has tripled since 1975. And is now a global issue. As technology has evolved, many weight loss, surgeries and procedures are available and we're gonna be discussing their benefits today, today, I'm joined by Dr. Kenneth Tieu, and Dr. Nathan Allison, they're both board certified general surgeons who have fellowship training in metabolic and bariatric surgery.

This is Putting Your Health First, the podcast from Health First. My name is Prakash Chandran. So Dr. Tieu and Dr. Allison, thank you so much for joining us today, Dr. Tieu, I'd like to start with you, how is someone medically considered obese and tell us about some of the dangers of being obese in the first place?

Dr. Tieu: Okay, to answer your question about how someone is considered medically obese, a lot of societies and definitions in medical professionals place a BMI criteria. So a BMI is called your body mass index. All it is, is the relationship between your height and your weight. So if you calculate your BMI and it's between 18 and 25, you consider it in the normal weight category.

If you're 25 to 30, you're considered overweight 30 to 35 is class one obesity. 35 to 40 is class, two obesity, and then 40 and above is class three obesity. There are many effects of obesity. Every single organ system is affected when someone's overweight or obese.

For example you have pulmonary issues such as sleep apnea. You have heart disease, high blood pressure coronary artery disease. You're at risk for strokes you're at risk for, type two diabetes. So you name it any organ system in your body would be affected by obesity.

Dr. Allison: Yeah. And one thing I would add Ken is lately, especially with the pandemic being so prevalent now, I think people need to understand that obesity affects also their outcomes from the COVID 19 virus. We've seen a significant increase in all cause mortality and morbidity associated with higher BMIs.

And in our area of Florida, we've had quite a few people succumb to the disease that normally should have done much better and it was directly attributed to their BMI, their body mass index. So I think in addition to the chronic conditions that we talk about, it's a real manifestation, if you develop one of the infections that we've been dealing with of late.

Dr. Tieu: Absolutely. That's a good point.

Prakash Chandran: Yeah, Dr. Allison, thank you so much for adding that. One of the things that we're obviously talking about today is weight loss surgery, and how that correlates to obesity is that I imagine people that have tried to lose weight and have been unsuccessful, might be looking at something like weight loss surgery to help them.

So, Dr. Allison, could you talk a little bit about the qualifications to become a weight loss surgical patient and what kind of the profile of someone looking for weight loss surgery might look like?

Dr. Allison: Sure. So there's a couple of criteria that we look at. So first you have to decide who's paying for the surgery. So, in the society of bariatric metabolic surgery that Ken and I are both fellows in, they look at BMI of 30 and above as being an acceptable candidate, if they have some comorbidities and things of that nature.

But unfortunately insurance doesn't typically pay for a BMI of 30 and above. And they don't start paying until you get to a BMI of 35. So if you're a self-pay patient and you wanted to have, say, for example, one of our bariatric surgeries if you came into us, you're BMI was 31, 32, 33, and you had comorbidities and we thought you were a good. You absolutely can have surgery, just insurance won't pay for it.

Insurance starts paying for surgeries when you get to a BMI of 35 with a comorbid condition, such as hypertension, sleep apnea diabetes, etcetera. And so there's a whole list of things that they consider a comorbid condition, or if you're a BMI of 40, and you do not have a comorbid condition, they also consider you an acceptable candidate.

So typically what we do is we have in a first time evaluation and we talk to the patient and we calculate what their BMI is. We talk to them about their comorbid conditions and then what their goals are in terms of what they want to achieve. What weight would they like to get to? What comorbid conditions, if any, would they like to see either diminished or completely cured from surgery?

Dr. Tieu: To add to that. I think that's a good point, Dr. Allison, I think a lot of people mistake the fact that you have to be a certain weight or have certain comorbidities to qualify for 30. A lot of that is just an insurance criteria.

we know that someone that has a BMI of say 30 has diabetes has sleep apnea, has hypertension. So how they have multiple comorbidities. Now that candidate may not qualify under the insurance guideline, but from a medical standpoint I still think that patient may benefit greatly from one of the weight loss procedures.

Prakash Chandran: So Dr. Tieu, just expanding on that a little bit. Can you actually go over the weight loss procedures and the differences between them?

Dr. Tieu: Okay. So when you talk about the three main procedures lap bend was known to be the least invasive of these procedures. That's how it , became so popular. I would say back in t he nineties and two thousands everyone that came in got lap bad because it was very low invasive and a quick procedure.

So in that procedure, what we're doing is we're putting a silicone band with a balloon around the top portion of your stomach. That in turn is connected to a port that is placed underneath the skin outside of the abdominal cavity. So what happens with that is every so often people would come in and they would get saline injected into that port, which will blow up the balloon.

What that balloon does, it restricts and squeezes on the top portion of the making your brain think your stomach is a lot smaller than it is. So when you eat, say a four or five ounce portions you feel full and you feel full until you get to your next meal. So really it's tricking your brain and making your stomach restrictive and able to eat a small portion.

And patients are able to lose upwards of about 50% of their excess weight. And like I said it's of all the procedures, one of the lesser invasive procedures . Then we have our sleeve got struck me, which this surgery was really popular in Europe when it first started out.

What it was designed for was for people who were super morbidly obese, we're talking their BMIs in the 60, 70, and 80. What happened was people would come in, they would perform a sleeve gastrectomy. And when I say sleeve gastrectomy, there's people mistaken the procedure for us putting a sleeve or some sort of object around the stomach.

That's completely false. What the sleeve gastrectomy describes is actually the sleeve of stomach that remains so. We do in the procedure and it's all done laparoscopically as well with some tiny pull holes on your abdomen, we go in and we remove approximately 70 to 80% of the stomach.

We leave a sleeve of stomach that remains, and you're able to eat same thing as you're well adjusted lap band four or five ounces and you would get full and satisfied from those portion. But again, it was designed for people who are super mobily obese. We would come in, do that procedure, get the patients to lose some weight.

And then it was designed to be a second stage procedure, which was either a dual switch or a gastric bypass. But what they found was sleeve patient were losing almost as much as their gastric bypass counterparts. And that's how it became a standalone weight loss procedure. And then we get to the third procedure, which is our ruin wide gastric bypass.

When we talk about gastric bypass, this is pretty much the gold standard in weight loss surgery. It's been around for 70 years. It was done with a big incision when it first started out. But over the years, Surgeons got better, surgical training got better. As we knew more about the procedures, we're able to do that procedure laparoscopic now again, through some tiny poke holes on the abdomen.

We're able to do a lot quicker. Patients are in the hospital for most of the time, two nights than they're out of the hospital. But what we do in that procedure is we go in and we create a small stomach out of the top portion of your normal stomach. And the remainer I would say 90% of the stomach is bypassed.

Then we take a part of your small intestine or your small bowel and hook it up to your new stomach. So when you eat, food fills up the small pouch, again about four or five ounce of meals will get you full. And then that food gets passed into the small intestine, which is more distal, a lot quicker.

So we're bypassing a major portion of the stomach and the first portion of your small intestine. So you do create a little bit of mal absorption. So all the calories you eat is not absorbed. So you do get a little bit more weight loss with the gastric bypass than it would say with the a lap band or a sleeve.

With the band, I would say 50% excess weight loss with the sleeve, I would say about 70, 75% of your excess weight. And then with the gastric bypass, we're talking about 80 to 85% of excess weight loss with that procedure.

Dr. Allison: Yeah. I think each surgery is different, but the beauty of what we do is we try to customize it to the patient's condition. I think Ken mentioned earlier that the lap band was done and was real popular in the nineties and two thousands because people were just putting them in, but they weren't really doing what we would consider a proper workup to make sure that is this the right surgery for the patient.

So, each surgery is similar in some respects, but different in others. And so we try to do a pretty thorough workup preoperatively to know which surgery is gonna be the most successful for the person. And then we apply that knowledge to the patient. so they don't have issues later. And I think that's been one of the most successful things of our program is tailoring the right surgery to the right patient.

Prakash Chandran: Yeah. So let's take the time to expand on that a little bit, Dr. Allison, can you talk a little bit about the process that patients go through, so you can make sure to tailor the right surgery to the right patient?

Dr. Allison: Yeah. So the process is pretty streamlined and whether you're a self-pay patient or an insured patient, that's having the surgery. The process is the same. So you have an initial evaluation with either myself, Dr. Tieu or one of our. Team. And the initial evaluation is just getting to know you, what your current BMI or body mass index is any of your comorbid conditions and then what your expectations are.

At that initial evaluation, what we're trying to assess is, are we gonna be able to meet your needs? And is it gonna be a safe surgery for you? Not everyone's gonna be a surgical candidate. So we have to kind of establish that right off the get go. If you're a good surgical candidate you're not a extremely high risk surgical candidate.

For example, you're not on a heart transplant list or you're not gonna have some issue that's gonna make it very difficult for us to do the surgery. And you're an acceptable surgical candidate. Then what we typically do is we do a few evaluations. We do a psychology evaluation that's governed and mandated by the society of metabolic surgery.

So we try to follow all the rules on all of those things. So everyone's getting a psychological evaluation, everyone's getting a nutrition evaluation. Everyone's getting an exercise physiology evaluation, which is really just helping us calculate your metabolic rates. So we want to know mind, body, and spirit that everyone is ready for the surgery.

We also do quite an intense educational series before the surgery. Just kind of getting people on the same level footing for what's a calorie, what's a protein, what's a carbohydrate, how to read a food label because some people do and some people do not know how to do that. And then as we're going through the process, we're just educating on where they're currently at, how many calories they consume, how much physical activity they.

And we use various apps for that. And then we try to get them to start losing weight immediately. From the first day we don't wait until surgery. And then as we go through the process is going to be, if there's something that we need to look at with your heart, we'll get that evaluated. If there's something going on with your kidneys or something going on with your lungs, we get all of those things analyzed and evaluated.

And then one of the things that we do that sets us apart from other programs is we do quite a lot of for gut and reflux workup as well for other surgeries that we do not bariatric. So we use that knowledge to be able to make sure that the surgeries that we're gonna be doing do not cause you to have a new problem.

For example, if you have a ton of reflux before surgery, we're not gonna recommend something like a band or a sleeve, because it's gonna make your reflux worse. We do an endoscopy that we will perform to make sure that you don't have any preexisting conditions that you may or may not even be aware of. Some of our patients have silent reflux that they don't even know it's happening.

So we'll look at the esophagus function. We'll look at the stomach function. We'll look at the person's ability To do digestion in the up portion of their anatomy before we ever do a surgery, that gives us the majority of our knowledge that we would need to make sure that we're making the right choice for someone.

For example, if someone has a condition called gastroparesis, which is fairly common with diabetes, we're not gonna wanna recommend, for example, a lap band. And with moderate or severe gastroparesis, we wouldn't recommend a sleeve. So those are things that we need to know prior to doing the surgery.

So once all of the workup is complete and we've got all of your evaluations, then we sit down and kind of create an entire storyline of, okay, here's where your journey's gonna start. Here's how we're gonna proceed. And then we usually choose the surgery by that point.

And I think one thing that's really important, and Ken might speak to this is people come in wanting a very specific surgery because their friend, or maybe a family member had that surgery. But that doesn't mean that surgery is the right surgery for you. And a lot of times after the workup, we end up changing the surgical plan because of the workup.

Dr. Tieu: That's absolutely right. I think, people come in and everyone here is built differently. Everyone has a different reason for being overweight. Everyone has a different reason for wanting to lose weight. So number one, we gotta pick the right surgery for the patient. And that's why we do all those extensive workups that Dr. Allison is talking about.

But the other reason why we have such a big team and we do an extensive workup and have all these follow ups is that at the end of the day, the surgery is a tool. It's just one part of the weight loss journey. If we give you the tool and you never use the tool correctly, you're not gonna lose as much weight, but if we give you this tool, which is a very powerful tool, show you how to use it, combine it with all the other resources we have.

Such a psychology, nutrition, exercise physiologist. If you combine all those things, I think that's what's gonna make the patient the most successful. Because if you just do the survey, never have the follow up that we have for our patients, you're not gonna be as successful.

Prakash Chandran: Yeah, absolutely. And I'm so glad you went into all of the comprehensive nuances that go into making the considerations, including like the psychological workup, because it is a very comprehensive decision. Dr. Tieu, you alluded to this. When you were talking about the gastric bypass, but can you talk a little bit about the surgical techniques and specifically the differences between minimally invasive and robotic surgery?

Dr. Tieu: Yes. like we talked about when we first started doing gastric bypass 70 years ago was through a large incision. And most of the times they were bypassing a large portion of your small and bowel, leaving only maybe a hundred to 150 centimeters of bowel remaining for absorption.

So you saw a lot of mal absorptive issues. In addition having a big open procedure, say for example, in a three or 400 pound patient, you're at risk for wound infections. The surgeries lasted 5, 6, 7 hours sometimes. So imagine having that patient under general anesthesia, on a ventilator for that long. Your risk of having blood clots, having bleeding risks pneumonias, heart attacks, all those goes way up.

But as we improved as surgeons and surgical training and even surgical technology improved, we were able to do these surgeries, minimally invasive. When we talk about minimally invasive it's through tiny, and poke holes, little incisions that are maybe half a centimeter. So back in, I would say about the 1990s, people were learning how to do this laparoscopically with laparoscopic instruments.

When I was in medical school, I watched some of the surgeons train and learned how to do these procedures that it would take them again, 7, 8 hours to do a laparoscopic gastric bypass. So, again as surgeons got better, that time came down now, we're able to do these surgeries in 90 minutes.

So imagine, going from 8 hours to 90 minutes, the risk of anesthesia goes down the risk of bleeding, the risk of heart attacks, the risk of blood clots come way down. And then with the advent of the robot is another laparoscopic tool. Imagine if we were to make the same , laparoscopic incisions, the same half centimeter incisions, and I'm able to put my hand through those incisions, that's what it is.

It's a robot, but really that's a misnomer, it's not really a robot. It's a laposcopic tool that we use. The robot does nothing without the surgeon. So the surgeon actually controls every single instrument that goes into the patient, but with the exact precision. Dr. Allison and I actually train doing bariatric surgery with robotics back in 2010.

At that time there were only three groups of surgeons in the whole country doing robotics. Because the training just wasn't there and now almost everyone across this country is doing it or wanting to do it with robots. So, we're proud to say that we were one of the very first people to do the bariatric surgery using the robot. We naturally published a paper showing the advantages and the lower complication rates with the robots.

Prakash Chandran: So Dr. Tieu, thank you so much for explaining all of the dynamics between laparoscopic and robotic surgery. It's something I've always wondered about. So thank you so much. Dr. Allison, the last question that I wanted to ask you is, I imagine that, once you get the surgery, your work is not complete.

So, can you talk broadly about the process that patients go through to make their weight loss surgery successful after the surgery itself?

Dr. Allison: Yeah. So, after the surgery, that's when the real work begins because you're going to now use all of the educational pieces we've given you in your day to day life. So for example, you're gonna watch your calorie intake. You're gonna watch your protein intake. You're gonna watch your carbohydrate intake.

You're gonna be getting back into the gym. You're gonna be doing a lot of things. For example, I always encourage people, maybe not in July and August, but in general to park further away from the building, walk in, take flights and stairs up as opposed to the elevator. Just simple things like that, because we want you to have a more physical and active lifestyle, if you can do those things.

Living in Florida, maybe not so much in the summer months. But that journey starts actually from the very first visit. And this is just another step in the continuum of the surgery. People get hung up on the fact that, oh, I'm gonna have the surgery and then that's gonna be it. But actually the real work begins.

So that's where we have our nutritional pieces. You've met with our team, the nutrition team. You're gonna continue to see them. You've met with our exercise team. You've met the mental health specialist, all those people are gonna be an integral part to continuing your journey. Like Ken alluded to earlier, people who are the most successful continue to follow with their program.

So our program is designed to have lifelong success and you can only have that if you're a lifelong patient. So we want you to see us routinely for just follow up and checkups. Just like, you'd go to your primary care and they're saying, Hey, your blood pressure's looking great.

We're gonna tweak a couple of things. You have to see them, at least once a year, the same thing with bariatric surgery. If you have the surgery, that is the tool that we've given you. And now we're just making sure that you're continuing to use the tool effectively. And if you do that, you're gonna have great success.

Prakash Chandran: Well, Dr. Tieu and Dr. Allison, thank you so much for your time today. I really learned a lot.

Dr. Tieu: Thank you for having us.

Dr. Allison: Thank you.

Prakash Chandran: Thanks for listening to Putting Your Health First, learn more about new fit surgical weight loss at hf.org/newfit. We look forward to you joining us again.