Transcription:
A History of Bariatric Surgery

manda Wilde (Host): Welcome to Flushing Hospital Med Talk. I'm Amanda Wilde. My Darshak Shah, Director Director of Bariatric Surgery at Flushing Hospital Medical Center. Shah, thank you for being here. Bariatric surgery has to do with weight loss, but what exactly is bariatric surgery? How does it .

Darshak Shah, MD (Guest): Hello,work Amanda. Thank you for having me here for the podcast and I'll be happy to talk about it. So, bariatric surgery by definition is any procedure that involves making changes to the digestive tract to induce weight loss. So, any procedure we do within the abdominal cavity, inside the abdomen that helps patient lose significant weight is defined as bariatric surgery.

Host: And is bariatric surgery relatively new? I feel like I've only heard about it in the last couple of decades.

Dr. Shah: Okay. That's a, that's an excellent question. So, if we look at what is documented in the history of medical literature, the first reported bariatric surgery was performed in the 1950s at University of Minnesota. And it was done to induce significant weight loss by performing a bypass of majority of the intestine, small intestine, which which is a tube in the body that helps absorb nutrients.

So, that is the first reported operation in the literature. Now things have evolved over time. Earlier, when we used to do these operations, they were done in an open fashion. And these were the procedures done on the stomach and intestine that led to significant weight loss, but there were also a lot of complications at that time with these procedures.

And over time we have evolved significantly. And you are right, in the last couple of decades because of the advancement of laparoscopic and robotic techniques that we now use for these procedures, the outcomes have drastically improved and the complications are going towards minimal and hence it has become more popular.

And every year we see that the adaptation of this procedure nationally, internationally, worldwide, is it's becoming more and more and people are hearing about it and considering it for significant weight loss.

Host: So, when you're doing bariatric surgeries, are you still addressing as you were in the 1950s, the absorption of calories or whatever it is that puts weight on?

Dr. Shah: So there are two different mechanisms by which the bariatric procedures that we do work. So, one of them is malabsorption that we spoke about, where we bypass a significant portion of the intestine and the stomach, that induces weight loss, but there is also a restrictive component, which means we make the stomach, the pouch that basically holds the food and sends signal to the brain that it is full or empty based on which we feel the hunger, that pouch is made smaller. And that is the restrictive component. So, along with that restrictive and malabsorptive component, patients do lose weight.

Host: So obviously that's the big benefit of bariatric surgery. Who is a candidate to, to get this? Who will benefit best from bariatric surgery?

Dr. Shah: Right. So over time the guidelines have been set and that's what we follow. And it's pretty uniform guidelines for all the insurance companies. And the best part that I really wanted to emphasize is that the insurance covers these procedures. These are not cosmetic. These are medically necessary for patients who really need them for the health benefit.

So, the guidelines that are set in United States have been in place since 1991 when NIH, National Institute of Health, put out the guidelines. Any patient who has a BMI, which is body mass index, which is easy to find online a BMI calculator, it's calculated by dividing your weight in kilogram by height and meter squared.

When the BMI is more than 35, along with a known associated medical problems which are high blood pressure, diabetes, sleeping problems in the form of sleep apnea, osteoarthritis; these patients are candidates, or if anyone has a BMI more than 40, then whether they have any medical problems or not, they are the candidates for bariatric surgery. In last few years, we are starting to expand the procedures to patients whose BMI is 30 to 35, along with uncontrolled diabetes because all these medical problems I spoke to you about, they are all related to obesity.

Host: So reducing obesity also reduces these medical problems and symptoms that people are having such as diabetes?

Dr. Shah: Correct. So, the patients can have significant effect on diabetes, high blood pressure, sleep apnea, osteoarthritis, hyperlipidemia. When we look at the efficacy of bariatric surgery, it's not only about weight loss that we are looking, a successful bariatrics surgery is helping patients lose significant weight along with resolution of their medical problems.

So, when we, when we quantify it and we kind of talk about the average weight loss after a bariatric surgery; in one year, most of the patients on an average would lose one third of their body weight. So, suppose a patient comes in to see us and start the program at 300 pounds, they would be able to on an average, lose a hundred pounds at the end of one year. There are some patients who would lose more. Some of them would lose less, but on an average, they would lose one third of their body weight. Now that translates to more than 50 to 60% of excess weight that they have, which means the weight that is in addition to their ideal body weight and 60% of excess weight loss is achieved at five to 10 years after bariatric surgery on studying them on long-term.

With the weight loss comes the benefits of resolution of these medical problems. So, number one is diabetes. So 60 to 70% of patients who come in to seek attention for weight loss surgery have diabetes. And at one year when they have achieved their weight loss, 60 to 90% of patients, depending on the studies in the literature, have resolution of diabetes, which means they would not need any medications after losing that weight. Same is true for high blood pressure, 50 to 80% of patients would not need any medications for high blood pressure. And pretty much most of them would, if they are not completely off their medication, they would be requiring much less doses of medications compared to what they were needing before. Same thing with sleep apnea. When patients need machines to help them, a bipap machine, to help them breathe when they are sleeping, the need for that bipap machine significantly reduces and then 60 to 70%, the need is gone. They don't have sleep apnea anymore. Same with hyperlipidemia, elevated cholesterol and osteoarthritis. Something that all my patients when they hear and they read that, really catches their attention, is it significantly reduces the risk of cancer for breast, colon, these cancers and, and in there. So the risk of cancers for breast colon, endometrium, ovary, all of these go down as well.

Host: Wow. So, this bariatric surgery is really about resolution of medical problems through weight loss. So, is this the most direct way to address the problems you were mentioning such as diabetes or high blood pressure, high cholesterol or sleep apnea?

Dr. Shah: So that's, that's the focus these days. When we are looking at curing a problem, we want to cure it from the root so it does not come back. Now when we follow these medical problems and we have multiple studies in the literature where we compare the result of medical management versus the surgical management and the surgical management, obviously, when they qualify for the, for the bariatric surgery is much more significant and efficacious compared to the medical management. Now, if I have a diabetic and their BMI is 25, they will not qualify for the surgery, but when they qualify, nothing is better in terms of the effectiveness of the procedure, then bariatric surgery.

And that is well-documented in multiple randomized study in the medical literature now.

Host: Wow. So once someone has decided to go with bariatric surgery, what should a patient expect after the surgery in terms of recovery and what are some of the benefits and potential complications?

Dr. Shah: Sure. So, so when the patients come, the first initial consult, we make, we try to go over all of this in detail. It's a program where patients have to go through evaluation by a pulmonologist, a cardiologist, a psychiatrist, a nutritionist, see their medical doctor for few months before we get them approved by the insurance company.

At the same time, we guide them how they can lose weight before the surgery, which is highly recommended. And we motivate the patiens. Nutritionists speak to them, as surgeons, we speak to them. What are the different modalities by which they can lose weight before the surgery. And then on day of surgery, the patients come into the hospital, Flushing Hospital. They meet the staff in the morning. The nurses help them admit and anesthesiologist would come and speak to them. And then patient goes to the operating room. The operating room, the patient, is there anywhere between an hour to three hours, depending on what kind of procedure, if patients have previous surgical history.

So all of that factors in there. When the patient comes out, they go to the recovery room and they typically stay there for a couple of hours while they are recovering, recovering from the anesthesia. And then they go to their bariatric designated bed where the team of nurses who are excellent at Flushing, that's the feedback I always get from patient that they were very well taken care of while they were recovering from the surgery.

So they would stay there typically for one night. And next day, when they are tolerating their liquids, pain is controlled, there's no nausea, vomiting, we send the patients home. So the stays only one night in the hospital. And then because we implement laparoscopic and robotic technique, the recovery is very fast. The patients pretty much get up and they are walking the same day of surgery or the next day. And that's what we encourage them to do as well.

Host: What's the follow-up after the surgery has happened and the patient has been sent home?

Dr. Shah: Sure. So something that I tell my patients is once you are my patient, once I operate on you, you are my patient for life. And the reason for that is we want to very closely follow these patients. Help them lose weight and it's early on and it's not only about early on, the main thing is to make sure that they are on track to lose the weight and stay there instead of regaining the weight because of many different reasons that one can in, in the future.

So the followup is, they followup in the office a week after they are discharged from the hospital and then a month later and then three months, six months a year, and then every year.

Host: You're saying this has been highly successful on the longterm. When a patient is starting this journey, what should we be looking for when choosing a surgeon and a hospital to have bariatric surgery?

Dr. Shah: Right. So, because of the adaptation of bariatric surgery in the surgical community in last decade, we have come up with Bariatric Center of Excellence Designation. Now American College of Surgery, they came out with very strict guidelines which is followed by the center of excellence, where we have to report each and every patient that we operate to see the outcomes.

And we were one of the first hospitals in Queens to achieve that designation. And we have had it for over four years. And so we are very proud to say that we, our Center of Excellence in Bariatrics in Queens and our outcomes have been, since we can follow, because of this designation have been really good compared to national average in terms of any complications of or readmission, which is very rare with these procedures.

Host: What makes you so successful? Is it your, your team approach? Is it the support services you have? Why are you a center of excellence?

Dr. Shah: Right so it's, it's always a team effort. Surgery, moreso, bariatric surgery is, is is a team approach that always leads to successful outcome. It's not only about the surgery. It's about the support that the patient gets before, during and after surgery that makes the entire program very successful. We have dedicated, we are a team of two surgeons, bariatric surgeons with a registered dietician in the office who sees the patient multiple times before the surgery and after the surgery. We have a group of specialists who evaluate the patient for their psychiatrist, psychiatry and mental preparation before. And they have the support after the surgery as well, which is very important part of this weight loss journey. The patients have to be mentally prepared before and after for the whole entire process that helps them lose weight. We also have cardiologists, pulmonologists, gastroenterologists who are highly trained and also specially in taking care of these bariatric patients who might have little bit different need compared to the regular community.

And all of this helps us take care of the patients for bariatric surgery in a more specialized way. One thing that we have added to our program as of last year is having a dedicated patient navigator. What she does is she would follow the patient through the entire process. Since sometimes it's three to six months of preparation that we need between seeing these specialists and the medical doctor. A lot of time, patients feel overwhelmed and confused, and that's what she is doing is taking all that anxiety away. She would coordinate everything with the patient and help them get to the day of surgery and after to alleviate their anxiety and help them with their appointments.

Host: So you're always evaluating and making improvements based on what you see patients' needs are.

Exactly. And that's what the program has been. And that's one of the important reasons why the program has been successful. I see my patients pretty much every month while they are getting prepared to help them through the process. And I see the patients myself, not my nurse practitioners or MA or PAs. It's me who sees the patient and evaluates them every month.

I just want to thank you, Dr. Shah for an informative and nicely comprehensive explanation of bariatric surgery.

Dr. Shah: You're welcome, Amanda. And thank you for having me for the podcast.

Host: For more information about the services Flushing Hospital offers visit our website at flushinghospital.org/podcasts. All content of this podcast is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. PLease consult a medical professional before adopting any of the suggestions discussed on this podcast. I'm Amanda Wilde. Stay well.