Transcription:
The Benefits of Weight Loss Surgery

Melanie Cole (Host):   Have you tried to lose large amounts of weight only to get frustrated? Are you considering bariatric surgery? My guest today is Dr. John Yadegar. He is a bariatric surgeon and the Director of Metabolic and Bariatric Surgery at Palmdale Regional Health. Welcome to the show, doctor. Tell us a little bit about bariatric surgery. Who are good candidates for this type of surgery?  

Dr. John Yadegar (Guest):   Hi, Melanie. Thank you for the opportunity. As you know, this issue with obesity has gripped our nation in a big way since a lot of patients suffer with this disease. We know through years of studies that the most successful approach to intervention is a surgical approach but, as a part of a multi-disciplinary approach, that should include patients improving their lifestyle. Eating healthy, exercising and being fully informed about what surgery entails. The surgical approach for obesity has been around for more than 20 years but we have perfected the art now. It has been done as a minimally invasive approach, which means these operations are now performed through small incisions which allows these patients to have a faster recovery, less pain and faster return to work. There are three main operations that are carried out in the United States. There are some rare operations – but of the main three one of them is laparoscopic gastric bypass surgery, which is referred to as Roux-En-Y. The second is laparoscopic sleeve gastrectomy and the third is laparoscopic gastric banding, which is to many people known as a lap band. 

Melanie:  If people are hearing you say “laparoscopic”, tell them what that means and just how invasive these surgeries are.  

Dr. Yadegar:   Laparoscopic surgery just refers to the way that we access the abdominal cavity. Through small incisions, a camera is inserted which is a magnifying telescope, essentially, that allows us to visualize the organs internally and then, using these very fine instruments we access these areas of the abdomen, such as the stomach and the intestines, and we complete the surgery through these small incisions. When the patient actually wakes up, they have three or four Band-Aids are on their abdomen and they are up and walking within three hours of surgery and are able to drink the next morning and are out of the hospital within 48 hours. It is a remarkable transition from the old ways where we used to have very big, large incisions, long hospital stays and potential complications. Now, these patients, after surgery, are up and about and get back to their baseline pretty quickly.

Melanie:  So, tell us what happens – we’ll get to the surgery – but tell us what happens before. If someone comes to see you, they’re morbidly obese, they’ve tried everything and they’re considering bariatric surgery, what happens before you decide that this is what they’re going to have?

Dr. Yadegar:   Usually, the patients may have had some encounter either with family members or through the media or through their primary care physicians and they have done a fair amount of research. They often come very well-informed but the opportunity at that first visit with the bariatric surgeon—and, for instance, with our program--is that we really take a whole hour to sit with the patients and number one, make sure that they are fully aware of what the intricacies of these operations are with regards to longitudinally, how does it impact them? Are they aware of the lifestyle changes that they have to adapt? It’s important for them to understand that these operations help with their weight but it’s only a tool. They really have to approach it as a global holistic approach. They have to start eating healthier. They have to start being committed with an exercise routine to start actually losing weight before surgery so that they can validate that, once they do have the surgery, they will for sure do well with that. But even in that scenario, there are 20% of the patients that may, through time, regain some of that weight. It’s very important from the front end that they are well-informed, they recognize the changes they have to make. That will include certain things such as making foods at home that are healthy as opposed to eating out or having fast foods; exercising where they get an opportunity, either every day at work between their lunch time and the next part of the day to go out and walk or, in the evenings; or, actually have routine on the weekends where they go to the gym and do some cardio exercises. As a result of this, usually when one member of the family starts to eat healthier, the others also jump on. It’s impact which is a domino effect. One member of the family starts to do that, others come along and that’s really a wonderful thing to see. There is a lot of emphasis on education and once they see that and the patients themselves get motivated, then they are ready to proceed. Then, we’ll go ahead and transition them through to the operation and, of course, support. Support is crucial – from family, from friends and from the program. We have a very extensive program where we spend, sometimes two to three months before surgery, educating these patients, bringing them back to classes, having them meet with the nutritionists. Often they have to have a psychological evaluation to make sure that they really recognize the intricacies emotionally in terms of body image and their eating pattern changes. Once they have fully committed themselves then, of course, they go through surgery. Afterwards, they have support groups. We are very hands on and it’s important for the patients to recognize that it is not just surgery and then they are on their way. It’s an ongoing process, an ongoing commitment to lifestyle change and exercise, supplementation, making sure they take vitamins and they stay committed for the rest of their life and they follow up. To avoid that and not be followed up down the road can actually compromise their success. It is very important for them to recognize that. We are always available if they need us.

Melanie:   I think one thing people don’t realize is this is not just for weight loss, it’s a tool to help and aid in it which is why it is so important, as you mentioned, follow up and education and changing their lifestyle. How do you decide with them which of those three we’ve mentioned that they’re going to have?   

Dr. Yadegar:   There are certain statistical parameters that, through the literature and studies that have gone on over the 20 years, we kind of know, perhaps, which operation will be best suited. There are no absolutes. It is important that we always spend time and educate the patients about the three options predominately, as I alluded to earlier, and then explain to them what each one can potentially do for the patient. With the patients that are what we call “super morbidly obese” – typically that is defined as a body mass index of greater than 50. This would be a typical 350 pound patient at a height of 5’8”. Let’s say they have had some trouble with diabetes or high blood pressure and metabolically they are showing signs of what we call “metabolic syndrome”. In this patient population, bypass may prove to be a better choice because of the changes in terms of endocrine and the biological changes that happen soon after the gastric bypass. The diabetes – typically Type II diabetes in these patients--improves within days. For that class of patients that are super morbidly obese and have diabetes, the bypass may be a better match. It’s really what is a better match for an individual patient. These operations are not one for all. It is really very selective for individualized patients. If you look at someone who has a lower body mass index, let’s say you have someone who is 5’8” but has a weight of 260 and no co-morbidities and, let’s say their body mass index is 40 or higher, they may do very well with a sleeve gastrectomy. In that scenario, they will understand that it will give them very good weight loss, very good resolution but it’s not, perhaps, an approach that is malabsorptive so nutritionally, although they have to continue to take supplementation, they have a little bit more resilience in that respect. It’s very important for the patients to recognize the subtleties of the differences between these operations. We spend a lot of time with them and often, by them reading around the literature and then we also encourage them to meet patients who come to our support groups before they commit to the choice. That way, they understand, really, what these operations are all about and then they make a decision. Often, they come to make the right decision for them. They usually gravitate to what is the best match for them. 

Melanie:   Are any of these reversible?   

Dr. Yadegar:   Let’s present it as such. With the bypass, the approach should be for any patient to recognize that this is one chance, one opportunity and one surgery and not to have to want to go back and have another one. But having said that, of course if there are any potential complications, one has to go in and attend to it. If a patient has a bypass and for some reason, years down the line feels that, “I no longer want to have this operation in me and I want to have it reversed”, it is reversible. It’s complex. Anytime you have multiple surgeries, your potential risk go up, but it is technically feasible. The sleeve gastrectomy is an operation where the stomach is downsized so 75-80% of the stomach is removed. In that scenario, there is no reversibility because the original stomach, most of it has been removed. I often tell patients, “It’s like having your wisdom teeth removed. You still have a fully functional operational mouth. You can still chew but you just have less teeth.” But your wisdom teeth are now removed, you can’t get them back. With that operation, really there is nothing to talk about with reversibility.  The laparoscopic band is an operation where we, of course, place this ring which is an elastic or silicone ring on the junction of the food pipe and the stomach. That has a chamber that is connected to the ring and that chamber sits underneath the abdominal wall often on the left side but it could be on the right or the middle. By injecting that port or that reservoir the ring can tighten. Through that, the patients often start to feel satiety with small portions. That lap band can be removed if they have problems or they do not want to keep it. Again, a second operation is always more complex. It is important before the patients commit to a choice that they really understand what each of them are about so that way, hopefully, they are not going to at six months or a year later, want to have a second operation. In terms of outcomes, these operations all give patients good weight loss, again, recognizing that it is part of lifestyle change and exercise routines and eating healthy. They all have shown in the various studies to contribute towards good weight loss and good resolution of co-morbidities. In terms of their percentiles the bypass offers approximately 80-85% of the patient’s excess weight loss. So, if there are a hundred over their ideal weight they can expect to lose 80-85 pounds.  

Melanie:   Wow.  

Dr. Yadegar:   The sleeve gastrectomy patients would typically expect to lose 75-80%, especially the younger patients who are a little metabolically more aggressive. They may even lose 80-90% percentile.  The lap band patients typically 50-55% percentile of their excess weight. They certainly are effective but there are potential risks and hazards with all surgery although these are very, very low because these patients are very heavily worked up prior to surgery. These operations are now so standardized that the outcomes are typically very good.

Melanie:   In just the last few minutes, Doctor, what should people who are considering bariatric surgery think about when seeking care?

Dr. Yadegar:   I would like them to study the subject and there is so much available on the internet but I also want them to go to reputable sites. The American Society of Metabolic and Bariatric Surgery has a lot of good literature. They should certainly talk with their family about their decision because it will impact them first and foremost, so they have to be ready mentally and emotionally, psychologically and socially. I think the family is an important, integral part. They should speak to their primary care. Sometimes physicians, primary care, may not be big advocates. In 2016, the majority of the primary cares are now aware of the good outcomes but still patients should have a conversation with their primary. If the primary care is not certain about it or doesn’t know much about it, that shouldn’t preclude the patient seeking a recommendation or advice from a bariatric surgeon. I think it is important for them to go out there, talk to the surgeon and find out about the program, find about the support system, find out about their outcomes. Then, of course, if they are interested, to go ahead and have a formal visit again with the surgeon for a second time and then, make their decision to proceed. 

Melanie:   Why should they come to Palmdale Regional Medical Center for their care?  

Dr. Yadegar:   Palmdale has been now conducting this operation for the last 11 years. It is been approved as a Center of Excellence. It has been awarded five stars by various grading authorities in the U.S. and it’s been recognized as the top ten percent in the country as a bariatric surgical program. So, we have had an outstanding track record. It is a stellar program. The reason is that it is very hands on. It’s very much of a team approach, it’s multi-disciplinary. Everybody who is engaged with the bariatric patients has been fully trained and has really invested a lot and they are a very compassionate, loving group of staff that care truly about their patients. That is really what you want when you’re a patient going for this. It does need somebody at the other side to be there for you, 24-7. We pride ourselves in really giving that support and giving them the best care. The outcomes that we have had really show that. The patients have had really good satisfaction from the program. We really get most of our patient population through referral and word of mouth. We have our door open. We always encourage patients to call if they have questions. We really don’t want them to be out there plundering about when things are not certain. That’s what I think what makes us very different to some of the other programs. The hospital is a state-of-the-art, brand new facility and patients have wonderful experience. We look forward to being available for them, if they choose us.

Melanie:   Thank you so much. It’s great information and so important.  You’re listening to Palmdale Regional Radio. For more information you can go to PalmdaleRegional.com. That’s PalmdaleRegional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks so much for listening.