Transcription:

Amanda Wilde: Weight loss surgery can be a tool to improve your health. Here to talk about it are bariatric surgeons, Dr. John Scott and Dr. Wes love. This is Flourish, a podcast brought to you by Prisma Health. I'm Amanda Wilde.

Dr. Scott and Dr. Love, welcome to you both. Dr. Scott, who is a candidate for bariatric surgery?

Dr. John Scott: That's great. Certainly, there are certain rules that insurance companies place on who can receive bariatric surgery and who can't. But in a nutshell, if you have a body mass index greater than 40, then you are a candidate for surgery, or if you have a body mass index greater than 35, and you have medical conditions related to your weight, such as type 2 diabetes, high blood pressure or high cholesterol.

Amanda Wilde: So Dr. Love, what are the surgery options and how do you choose which one is best?

Dr. Wes Love: So there are certainly multiple surgical options nationwide that patients may read about online. But particularly at our institution, we offer patients both the old standard, which is a laparoscopic Roux-en-Y gastric bypass as well as a laparoscopic sleeve gastrectomy or vertical sleeve gastrectomy.

With regards to which operation is right for which patient, that's actually a really good question. And the answer to which is something that involves a conversation between us, the surgeons, and the patient themselves. And that's one of the main focuses of the patient's first visit. For me personally, I think the same is true of Dr. Scott, there is actually a very powerful risk analysis tool that's put forth by the American College of Surgeons that we can go over with the patient and kind of give them specific tailored risks and benefits for each operation relative to just them, not just some random person. Particularly to dumb it down, or I guess parse it down a little bit. I typically think of much higher BMI patients as being better candidates for a gastric bypass. And in particular, if the patient has health problems such as really bad gastric reflux or specifically really bad diabetes, then that's a patient that I would try to counsel a little bit more towards the bypass over a sleeve. It's not that the sleeve's a bad operation, but you're going to have better success in reducing those comorbidities with a bypass in that case..

Amanda Wilde: So what are the risks associated with weight loss surgery, Dr. Scott?

Dr. John Scott: Well, there's certainly short-term risks and there's long-term risks. Now, we are of the opinion, and I think the scientific evidence bears this out that the benefits of bariatric surgery far outweigh the risks of surgery. However, there are risks with every surgical procedure that you have done, whether you're getting your appendix taken out or your gallbladder, or if you're having bariatric surgery.

Now, in the short term, there are some things that we worry about and we certainly worry about issues like bleeding and obstructions and problems with nausea and vomiting. But those are pretty low. In fact, right now, as it stands, bariatric surgery has gotten so standardized and we've really worked on improving our quality from a nationwide standpoint that bariatric surgery is technically safer than having your gallbladder taken out. And we know that gallbladder surgery is probably the most common operation done in the United States right now.

In terms of long-term things that we worry about, you worry about issues with gaining a little bit of weight back. But those risks are pretty low. The average bariatric surgery patient will keep their weight off for an extended period of time, 70% to 80% of the time.

Amanda Wilde: Ah, so I was going to ask, how do you prevent weight gain after you've had the surgery?

Dr. John Scott: So it's not a matter of preventing weight gain. You know, the surgery is just a very small part of the patient experience when they come through our program. There is a complete re-education about a patient's approach to food and physical activity through behavioral counseling, and dietary counseling, exercise therapy and psychological assistance as well, because we want to treat the whole patient. We're not just doing the anatomic part. But the beautiful thing about the surgeries that we offer is that it actually kind of resets the body's internal thermostat about where their weight should be. And so when the hormones and the brain gets a reset for a lower weight, then the patient will actually try to defend that lower weight and it really is resistant to gaining weight.

However, it's not a perfect system. The human body's an incredible machine is designed to, you know, when there's excess calories around to convert those calories into fat. And so, if we see a patient that is having some issues with weight regain, we kind of understand that's just part of the disease process. And there are a lot of interventions that we can do even after surgery for people that are one, two, three, even ten years out, things that might include, you know, additional behavioral therapy or using medications to help with appetite and weight loss or even revisional surgery.

Amanda Wilde: So, this resets the body's sense of where it should be. And then there is some followup afterwards to keep you on track. And it sounds like it's very individually oriented and pretty safe. So Dr. Love, how much weight can you lose? And how long does it take to lose that weight after bariatric surgery?

Dr. Wes Love: So with regards to weight loss, we typically refer to it using something called excess body weight loss. So not to get too technical with the math, but in a sense, your percent of excess body weight loss would be how much more you weigh than what you should to be reasonably healthy. So to keep the math basic, if you weigh 200 pounds and in a perfect world where you were totally healthy, you should weigh a hundred pounds, then you have a hundred pounds of excess body weight. And people can lose up to 80%. I've even seen patients with 90% of excess body weight lost. And typically tell patients that you can expect to lose weight for about the first two years after the operation, but the peak of that weight loss is going to occur within the first year.

Amanda Wilde: So that's probably really encouraging as you move on gender the second year. If you lose such a great amount of weight, isn't there a consequence to that, saggy skin or other things that happen to your body when it drops that much?

Dr. John Scott: Go ahead and take this one, Wes. So I think that there are definitely physiological consequences of the weight loss. The first thing that we see almost immediately after the surgery is a reversal of some of the medical problems that are associated with weight, especially type 2 diabetes. The remission rate for type 2 diabetes can be incredibly high depending upon how bad your diabetes is and your procedure choice. So that's one of the first consequences we see.

And the second thing is that your body goes through a process of trying to remodel itself as far as where fatty tissues are distributed and where you lose weight first. And yeah, there are going to be a small proportion of patients that do have issues with excess skin. I think that the best way that I communicate that to the patients is I say about 50% of all of our patients that lose weight are going to have issues with excess skin. But not everybody has the desire to have additional surgery to have that excess skin removed. And so of the patients that have excess skin issues, only about half of those actually seek consultation with a plastic surgeon for skin removal. And of those that meet with the plastic surgeon, probably only about half of those actually go through with something. So the percentage of people that go on to have plastic surgery for excess skin removal is actually quite low.

Amanda Wilde: So there is a surgical way to address that, but most people don't choose it.

Dr. John Scott: That is correct.

Amanda Wilde: Dr. Love, did you want to add to that?

Dr. Wes Love: I would just add that we, from the very beginning, start kind of coaching people to stop thinking of this as plastic surgery for your belly, you know. I'll even go so far as to say that just the weight loss by itself, you know, the satisfaction of seeing the number on the scale get smaller in my mind is a very nice side effect of the surgery. We spend a lot of time coaching people to consider this kind of a total health overhaul. And the fact that you get smaller and look better in the mirror is nice, but what's even nicer than that is that your comorbidities get better. Your hypertension improves, your diabetes goes away and you live longer to hang around with your grandkids.

And so I think on the heels of that mentality is sort of what leads to the effects you see that, you know, people might look into a little bit of, "Oh, the saggy skin that I have is maybe a little bit annoying," but that's not really the main focus of where they even started. And so it kind of peters out by the end and people don't seem to be as worried about it because of the overwhelming health benefits.

Amanda Wilde: Thank you, Dr. Scott and Dr. Love, for explaining bariatric surgery and what to expect. This has really changed my perspective from what you just said, Dr. Love, from weight loss to just healthy living. For more information on other podcasts, visit prismahealth.org/flourish. This has been Flourish, a podcast brought to you by Prisma Health. I'm Amanda Wilde. Be well.