Amanda Wilde (Host): Meaningful Medicine is a Novant Health Podcast, bringing you access to leading doctors who answer questions they wish you would ask from routine care to rare conditions. Our physicians offer tips to navigate medical decisions and build a healthier future. I'm Amanda Wilde. And joining me today is bariatric surgeon and bariatrician, Dr. David Voellinger. We'll learn about the latest innovations in bariatric surgery and the outcomes and how Novant Health is approaching bariatric care. Dr. Voellinger, thank you so much for being here today.

David Voellinger, MD: Glad to be here. Thanks for having me.

Host: To start, can you share how the field of bariatric surgery has evolved in recent years? I know there've been a lot of advancements, and I'd love to know which ones you're most excited about.

David Voellinger, MD: Absolutely. I've been doing it over 20 years. So, I've seen a lot of changes over that period of time. Interestingly, the audience might be interested to know that actually bariatric surgery started from ulcer surgery. The patients back in the day before Protonix and Prilosec, they were having more ulcers. And when physicians would do the ulcer surgery, removing part of the stomach, they realized, "Hey, these patients lose weight. They get healthier."

So from that, with big incisions, big ulcer surgeries, I've seen over the last 20 years our advancements into smaller incisions, what we would call minimally invasive surgeries, the laparoscopic techniques; even more recently, robotic-assisted techniques. A lot of changes in the stapling devices that we use to divide the tissue, seal the tissue. Energy devices have come a long way, and it's allowing us to take care of blood vessels. There's new hemostatics that we can use to help prevent bleeding. And I think one of the most exciting that I have been a part of is enhanced recovery after surgery, or ERAS as it's known.

Since about 2017 at Novant, our bariatric program has added an entire protocol that allows our patients to have a less pain, less nausea, less hospital stay, quicker recovery, dramatically improving all that. So, I think those are some of the things that I'm most excited about, in addition to outcomes. So, you know, we have seen, when I first started doing this 20 years ago, and I would do an informational seminar, I would tell my patients, "Your chance of dying from the surgery is about one in a hundred." Now, when we do the same thing, it's about one in 10,000. So, dramatic changes in outcomes. So as, we've developed data over the years, we've seen tremendous improvements in diabetes, hypertension, blood pressure, cardiac disease. So, I think the outcomes of the surgery, along with the technologies of improvements of the surgery really have been exciting.

Host: Many people still think of bariatric surgery as a last resort. Is that true? Or where does it fall in the care of weight management?

David Voellinger, MD: Yeah, absolutely not, right? It is part of the standard of care for the treatment of the disease of obesity. And we look at lifestyle management, medical management, surgical management. It's a tool. For a lot of patients, it is their best choice, depending on various factors, age, weight, medical condition.

And then, the other thing I'd really say is a lot of people say when they have surgery, they're giving up, right? That's not it at all. It's really patients are taking charge of their health. They're making a decision to live a longer, healthier, better life by having surgery than not doing anything where their chance of developing problems and living shorter period of time is much higher.

Host: When patients come to see you, what do you want them to understand about the role of surgery in long-term health and weight management?

David Voellinger, MD: I think, again, as I mentioned before, alluded to before, you know, this is a tool. Surgery is a tool, that we use to treat this disease. It can help with portion control, hunger control, obviously weight loss, and also weight loss maintenance. But it has to be used in the proper context. The foundation of everything that our patients should do is their lifestyle management. Are they eating and drinking the right things? Are they being active? Are they exercising? Are they managing their stress? Are they getting enough sleep? Surgery is only a piece of that treatment puzzle.

Host: So, surgery is not a golden key, and it is not a last resort. What are some of the other misconceptions you may encounter?

David Voellinger, MD: Sure. I think that, one, is that surgeries are always dangerous. I think I alluded to earlier, you know, gallbladder surgery, hip and knee replacement, back surgery, heart surgery are all way more risky than what we do today. Long hospital stays, our patients stay only overnight in the hospital, in some cases, maybe even go home same day.

So, I think that while it is considered a major surgery, we've advanced so far in our protocols, technology and technique, that it may not be as severe as you think. But on the other side of the coin, I do think it's important our patients understand that not only is surgery going to change your anatomy, and we're going to educate you on how to change your lifestyle, but it's also going to change the way you eat. It's going to be smaller bites, chew well, eat slowly. So, it's what you eat, how you eat it, with the end result being losing weight, living longer, living healthier.

Host: Along with the lower impact of this surgery, not having to stay in the hospital as long, and the minimally invasive techniques, what kind of outcomes are you seeing today, not just in weight loss, but are there improvements in other conditions people may have that are related, like heart disease or diabetes or joint health?

David Voellinger, MD: We see over 70% improvement in diabetes. In some cases, 20, 30% complete remission. We do say remission. It's not a cure, it's remission. If the weight comes back, you could potentially regain the diabetes as well. Hypertension, over 60% improvement or resolution. Cholesterol over 70%.

I think that one of the most exciting is that, when you think about heart disease, there's about a 50% reduction in cardiovascular events. Overall mortality, you know, are you going to live with severe obesity. There's a 50% reduction in all-cause mortality after bariatric surgery. So, just really spectacular numbers that very few things can do. Medicine certainly can't do all of that, but bariatric surgery can.

Host: How is Novant Health approaching bariatric care any differently than other institutions, especially when it comes to patient education and support and followup?

David Voellinger, MD: I think there's kind of two things. One is kind of our philosophy, and second is our comprehensive approach. And what I mean by philosophy is that, as I've kind of alluded to before, we see obesity as a chronic, lifelong relapsing disease. So therefore, to treat that, it's not going to be one thing, it's going to be multiple things because there's multiple causes of the disease. So, we believe that lifestyle, medical, surgical, integrative approaches, all of that needs to be combined. And not only is it combined in a multidisciplinary program, but it's combined under one roof. We have all those resources. We have that team there. Novant really believes in that approach, that under-one-roof approach is a comprehensive center. Also for lifelong, we follow our patients for life. We consider ourselves the primary care physicians of their weight. And so, we think that's very, very important to think about as well. We have classes, events, support groups, anything we can do to help them not only lose the weight, but maintain that weight loss and good health.

Host: And live a healthy lifestyle. And you just referred to those stunning numbers about how this surgery might affect other medical issues. Looking ahead, what innovation or research do you think will shape the future of bariatric medicine?

David Voellinger, MD: Yeah, there's a lot going on. From a medicine standpoint, we're seeing new and unique-- so right now, we have the single shot, the double shot. Well, the triple shot is coming with GLP-1, GIP, and glucagon. There's some different unique targets. Amylin and glucagon are a couple that you'll hear out there different delivery systems rather than shots, pills, dissolvables patches, different dosing schedules. You maybe hear something called microdosing, where you give smaller doses, extended dosing. Maybe instead of every week like a lot of the medicines now, it's every other week or once a month.

And then, we're real big believers in multimodal therapy, taking multiple drugs that go to different pathways, or medicines plus surgery as a combination therapy. Surgery, very excited about incisionless approaches where we're talking about minimally invasive now, but what about no incisions at all, using advanced robotic technology, advanced laparoscopic tests? All are equipment are continuing to evolve and advance. Magnetic surgery is something that's new where we use magnets to put the bowel together. That could potentially take care of some of the risks. Guidance systems intraoperatively, you're hearing some things about the glasses, things on the robot where we can see things better. And then, really trying to create hybrid procedures that are personalized for the patient. Everything's about AI and technology now, right? So, we want to use AI in our field to help to improve patient selection, what patients need, what operation, when do we need to best treat patients, what treatments are the best to choose for patients? Risk assessment, what are high risk and low risk? Doing remote patient monitoring where rather than when we see them in the office, but day-to-day monitoring of their weight and their health and using some of these new wearable monitors, we think that's exciting.

And, lastly, I would say in the research field, using the human genome, using their DNA to say, "Okay, what are the causes of obesity? Where can we target different things for treatments? Learning a lot about how the brain and the gut respond to each other. A lot of them do science, a lot of the GLP-1s came from that research. And then lastly, the microbiome of the gut, the bacteria that live in the gut, we're finding play more and more role in our health and our weight.

So, I know that's a lot, but there's a lot going on in this field, and excited about all those new developments. And Novant is certainly going to stay on the cutting edge of it all.

Host: We need someone like you to really keep up with that for us. Dr. V, for listeners who might be considering this step, what is the best way to start a conversation or learn if they're a candidate?

David Voellinger, MD: Number one, do your research, right? You can simply go online, go to a BMI calculator, and plug in your height and weight and get an assessment of where you are. If your BMI is over 40, you're kind of in that obese category, that severely obese category where you're going to need some sort of treatment now rather than later. Maybe if your BMI is over 30, you're kind of in the obese category and need to start working on things. BMI is over 27 is in the overweight category. So, I think kind of start there.

Talk to your PCP. Your PCP can give you some great advice on what you need to do next, and treatments that may be available. Talk to family and friends that have taken weight loss medicines or had surgery. I always encourage folks to go to some reputable sites online. A couple would be the Obesity Medical Association, the American Society for Metabolic and Bariatric Surgery, OMA, ASMBS. Those are great sources. And then, come see us at novanthealth.org/weightlossnow. There's a physician finder if you're looking for a particular surgeon or bariatrician like myself, or the location finder. There are bariatric centers in the Novant system in Charlotte region, Winston-Salem region, the Wilmington region, the Charleston region, just all over the Novant footprint. And our practice is Novant Health Bariatric Solutions. We're at Charlotte, Huntersville, Matthews, Steel Creek and Ballantyne. Certainly happy to help you in any way we can to get healthier, live longer, and live better.

Host: Dr. Voellinger, thank you so much for the invitation, the care you bring for sharing these updates. And we look forward to seeing what happens in the exciting future of bariatric surgery.

David Voellinger, MD: Thanks for having me. We're excited to be along for the ride, and a lot of good things are going to happen for our patients.

Host: That was bariatric surgeon, Dr. David Voellinger. To find a physician, visit novanthealth.org for more health and wellness information from our experts, visit healthyheadlines.org. This is Meaningful Medicine, a Novant Health podcast.