Transcription:
Reasons and Requirements for Bariatric Surgery

Melanie Cole, MS (Host):   When combined with a comprehensive treatment plan, bariatric surgery may be a really effective tool to provide you with long-term weight loss and help you increase your quality of life. This is Doc Talk presented by Montefiore St. Luke’s Cornwall. I'm Melanie Cole. Today we’re discussing bariatric surgery. Joining me is Dr. John Powell. He’s a board certified bariatric surgeon with Montefiore St. Luke’s Cornwall. Dr. Powell, it’s a please to have you with us today. Before we get into parameters for bariatrics and what that means, tell us what’s defined these days as obesity and the comorbid conditions that can come along with it.

John Powell, M.D., FACS, FASMBS (Guest):   Well first off thank you for allowing me to join. In terms of obesity, nowadays it’s more defined based on what’s called body mass index, also known as BMI. So when we have patients come and see us in the office what we get is their weight and their height. That turns into a ratio that’s called the BMI or body mass index. Based on a consensus statement that came out in 1991 the minimum criteria to become a candidate for surgery you have to have a BMI of 35. 35 and then above associate with some comorbid conditions. The most common that would be an indicator for as a definition for obesity as well as the surgery would be things like diabetes, obstructive sleep apnea, high blood pressure, high cholesterol, certain joint issues, fatty liver disease, and things such as this.

Host: So what can bariatric surgery do for patients? Tell us a little bit about what you’ve seen.  

Dr. Powell:   Yeah. The common knowledge nowadays is that this is a weight loss surgery. I’ll be honest. Whenever I see patients in the office the first thing that I tell them is that’s not my primary goal. I want them to lose weight and I can statistically kind of give someone good ideas of where they could potentially give up. The most important reason why we do the surgeries nowadays is really the medical reasons. Because those are the things that take away from life years. So if we can not only make your quality of life better but also more longevity, that would be the main reason why we do the surgeries these days.

Host:  So then while you're discussing this with them and then when people come to you, what’s required before surgery? You’ve already given us pretty much the parameters to what’s involved, and we’ve said this is a tool, as you say. So what’s involved in presurgical to get someone checked in? Is there psychological counselling? What do you do with someone?

Dr. Powell:   That’s a good question. So it is a bit of a process and most of it is defined by the patient’s insurance. So sometimes we tell patients before you come and see us you can also contact your insurance company and make sure that there's a plan in place and it’s covered benefits. When you come and see, you always see the surgeon the first time because we can answer, obviously, most of the technical questions. Then the next step is you actually sit with what we call our bariatric coordinators. These are folks that are not only experts at the insurance aspect to everything but also all the criteria needed to get through a program. The most basic thing is number one is nutritional information. Most of us nowadays learn most of our nutrition from fad diets or social media, etcetera. So we really have to get down to the nitty gritty. You’ll be sitting with dieticians and nutritionist and things like that. There's a behavioral component to it. So most insurance companies do require a psychological evaluation. The main reason for that is not to define a sanity or insanity issues. It’s to make sure that somebody is prepared for this next journey in there life because there is a lot of what they call life changes here, but obviously for all the better. Most programs will make sure folks are actually relatively healthy for a surgery meaning you’ll end up seeing a cardiologist or lung doctor or something of that nature. Most of it is based on the educational process that’s needed to be able to do well after the surgery.

Host:  As they're waiting to have surgery and going through this process, should they be trying to lose weight? Exercise? Or do they sort of put all of this stuff aside until this happens.

Dr. Powell:   No actually we do encourage it. Now most programs—Some programs will set a parameter. You may need to lose some weight. Certain insurance companies out there actually will define that you need to have some type of weight loss before surgery. Our program is a little bit easier in terms of the sense that we’re not looking for a direct number. We’re just showing that you're working towards it, you're learning, you're starting to apply it. We’re seeing the changes, and if you lose a couple of pounds here and there that is the benefit that we know that you're progressing within the program.

Host:  So tell us about the surgery. What kinds of surgery do you perform doctor?

Dr. Powell:   So there's two subsets? There's one that we call primary surgery which is basically the first surgery. The most common surgeries that we perform nowadays would be what we call the sleeve gastrectomy and then the sleeve bypass. Less common nowadays are surgeries like the gastric band. We do often at some points throughout the year being able to do revisional surgeries as well meaning somebody had a prior surgery and their needs o eb seen some changes in the future for various reasons.

Host:  So let’s talk about what you would choose gastric bypass over sleeve gastrectomy. What are the benefits? Are these malabsorption? Do they make it so you don’t absorb nutrients or you don’t take in as much food? Explain to the listeners the difference between these two types of surgeries and why you would choose one over the other?

Dr. Powell:   It’s a good question. So first in terms of a choice, I'm one of those surgeons where I want the patient interested in the process. So when we make a decision it’s always between us together. I'm not going to tell a patient you need X surgery. I'm going to help them make a decision. The reason for choosing though—the two most common is interest. Most folks coming already really have a good idea what they want based on what they’ve seen on TV, read about and as long as it fits the parameter which I’ll talk about in a second here. The other one though, really the biggest one, would be our severe diabetics. If someone comes in and they need a lot of insulin or they're on an insulin dependent regiment for their diabetes, out of both surgeries we know that the gastric bypass may have the longer term outcome of the higher resolution rate for that type of diabetes now. There's a lot of research now going back and forth about that, but I think the gold standard still would be the gastric bypass for our severe diabetes. For folks that are not though, they really can kind of choose between the two of them. There’s some plus and minuses between both of them in terms of what we’re looking for outcome.

In terms of the surgery—So just for the sleeve gastrectomy, for example, a lot of folks there's a misconception that we’re putting around the stomach to create that surgery. It’s the way we cut that stomach and the way the angulation of it, we make this narrow little tube of a stomach. That curvature looks like the sleeve of a jacket. So that’s where they got the name sleeve from. What that surgery does is two benefits. One obviously is eating less food but the bigger benefit—and this is what we talk about with the patients when they're in the room—is that there's a loss of appetite component because there's hormone changes that are ongoing. Versus the gastric bypass where we’re not only making a smaller stomach but we’re not only making a smaller stomach but we’re actually rearranging the bowels, so you do not absorb all the food that you eat. The benefit they found from that is not only long-term weight loss advantages but also that higher resolution rates of certain medical issues like diabetes because there's vast hormone changes that are occurring that we don’t fully understand yet. So huge benefits to both of them.

Host:  So thank you for that comprehensive answer. So what about right after surgery? Tell us a little bit about what life is like for them once they’ve decided and gone through this whole process and hand their surgery. The first couple of weeks, and do they have to take supplements for the rest of their life as a result?

Dr. Powell: So the post-operative care, most folks are relatively back to normal very quickly because most of the surgeries are done laparoscopic nowadays which means with the little incisions very similar to a gall bladder surgery. Most folks spend an overnight in the hospital. In terms of getting back to a normal lifestyle, most are averaging one to two weeks.  

In terms of dietary progression, so the most important thing after the surgery is we always want to make sure that folks are staying hydrated initially and then eventually getting their protein calories that they require. So for our program, for example, they're on liquids for several days after the surgery. Then they're on a liquid protein shake liquid diet with yogurts and things like that for about two weeks. Then for about two weeks they're on kind of soft mushier type foods to make sure everything goes down appropriately. Then right around about four and a half weeks out they're back to regular foods in terms of textures and qualities and things like that. The main reason for that five week transition is to allow them to make sure they stay hydrated, get the appropriate nutrition, but more importantly that they heal appropriately from the surgery. We don’t want any complications that can happen afterwards if somebody decides to start eating things inappropriately too quickly. So those things are discussed in detail through the whole process.

In terms of supplementation, most folks need to be on vitamins right now anyways. Most of us are actually vitamin D deficient and we’re finding this very commonly within most populations, but obviously within ours as well. So most of our folks will be on certain types of supplementation possibly short term, possibly long term, but through the process, especially post-operatively, we check vitamin labs very often especially in the first year and then usually annual thereafter. We can make readjustments, stop things, add things, whatever we need to do for a lifelong process.

Host:  As we said at the beginning, it’s a tool. So life after surgery. There's learning involved. There's exercise. As you said, there's all these lifestyle changes. What do you recommend, if you were to give your best advice, about things like going out to restaurants, reading labels, trying to use that tool to help them learn and change the whole way that they are living their life as far as food is concerned?

Dr. Powell:   Well I think the bottom line is to get as much out of a program as you can. So all the things that you just labeled there is everything that an appropriate program would be educating their patients on. S when they sit down with our dieticians, for example, you're not only learning good and bad choices but you're learning the idea of food label reading. Most of us don’t know how to read a food label appropriately. So that’s a very important part of the process. Going out to dinner, for example, we get lots of questions on that. These are things folks can absolutely do. We want them to live a very normal lifestyle. They're just going to be making better decisions. Portions and sizes are going to be different compared to life before surgery. So the bottom line I think is when you come to a program, get as much out of it as you can. Ask as many questions as you can. Come to our support group, come to our informational seminars. Ask patients, ask lots of questions. Really get involved in the entire thing and you can get as much out of it as you can. Those are the folks who have the best long term results.

Host:  Absolutely great advice. Before we wrap up, tell us about your team Dr. Powell.

Dr. Powell:   We have a tremendous team here. First of all they're all very friendly individuals, smiling faces. What we do here is a lot of fun because the whole point is the patients that are coming to see us have, beside weight issues, most of them have a lot of medical conditions. They're on a number of medications. Our goal at the end of the day is eventually you're going to hopefully be off of most of those. By the end of all of this, most folks are happier, healthier, just living better lifestyles. So what we do is a lot of fun here. We have a big team. So we have three surgeons in our group here along with a number of dieticians. We have at least three or four bariatric coordinator, psychiatry team, as well as all the other subspecialists that we have. So it’s a very large group here.

Host:  Thank you so much Dr. Powell. You’ve been so informative today. Thank you for sharing your expertise. That concludes this episode of Doc Talk presented by Montefiore St. Luke’s Cornwall. To contact the bariatric surgery team, please call 845-568-2825 or you can visit montefioreslc.org for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Montefiore St. Luke’s Cornwall podcasts. Until next time I'm Melanie Cole.