In the United States, around 15.5 million people suffer from severe obesity, according to the National Institutes of Health, and the numbers continue to increase.
Bariatric surgery is indicated for patients who are morbidly obese and already have tried diets, exercise, and other non-surgical means of losing weight. The bariatric surgery program at UAB Medicine has been performing weight-loss procedures for more than 30 years, and it is the first American College of Surgeons Level 1 Bariatric Surgery Center in Alabama. This history, combined with our standing as a respected academic medical center, puts UAB Medicine at the forefront of weight-loss surgery.
Listen as Richard Stahl, MD, Medical Director of Bariatric Surgery at UAB Medicine discusses the Bariatric Surgery program and how physicians can refer a patient to the Bariatric Surgery program at UAB Medicine.
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UAB Bariatric Surgery Program
Featuring:
Learn more about Richard Stahl, MD
Release Date 4/15/2020
Expiration Date 4/15/2023
Dr. Stahl has no financial relationships related to the content of this activity to disclose. Also, no other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity.
Richard Stahl, MD
An Alabama resident since childhood, Richard Stahl, MD attended Auburn University where he graduated with highest honors and a BS in biology. He received his M.D. degree from The University of Alabama at Birmingham School of Medicine, and completed his internship and surgery residency at Carraway Methodist Medical Center in Birmingham. He entered private practice in 1994, ultimately forming Cahaba Valley Surgical Group, and practiced a full range of general surgery including gastrointestinal, breast, thyroid, and parathyroid diseases. However, he gradually focused most of his attention on bariatric surgery.Learn more about Richard Stahl, MD
Release Date 4/15/2020
Expiration Date 4/15/2023
Dr. Stahl has no financial relationships related to the content of this activity to disclose. Also, no other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity.
Transcription:
Melanie Cole (Host): Bariatric surgery is indicated for patients who are morbidly obese and already have tried diets, exercise, and other non-surgical means of losing weight. The bariatric surgery program at UAB Medicine has been performing weight loss procedures for more than thirty years and it is the first American College of Surgeons Level 1 Bariatric Surgery Center in Alabama. My guest today is Dr. Richard Stahl. He’s the medical director of Bariatric Surgery at UAB Medicine. Welcome to the show, Dr. Stahl. So, let’s start with some parameters for consideration of bariatrics. When a patient comes to you, what are you looking for?
Dr. Richard Stahl (Guest): The criteria that we use are still based on the National Institute of Health Criteria that were set back in 1991. Patients with a body mass index of 40 or above would qualify for bariatric surgery regardless of comorbidities. Patients with a body mass index between 35 and 39.9 would qualify for bariatric surgery if they have comorbidities that are obesity related.
Melanie: So, what about the psychological aspect? And, what do you tell your patients about dealing with the aspects of this surgery?
Dr. Stahl: You’ve touched on a very good point. For many patients that are undergoing bariatric surgery or that are considering bariatric surgery, they may have some psychologic issues such as depression. And, oftentimes those psychologic issues might be related to their weight. In other words, their weight is driving that particular emotion or problem that they're having and, therefore, treatment of their weight often times improves that. We don’t see psychologic pathology in obese patients at a higher rate than we do in non-obese patients other than obese patients do have a somewhat higher rate of depression, though that seems to be due to their obesity. In addition, for patients undergoing weight loss surgery, they are sometimes losing what was for them a coping mechanism. By that I mean, some patients eat, perhaps overeat, perhaps because they’re stressed. Sometimes we overeat because we’re happy; sometimes because we’re sad; sometimes we overeat because we’re lonely; any number of reasons why we might overeat. And, once you undergo weight loss surgery, that particular coping mechanism (i.e. overeating) has been taken away from you. Now, for many patients, that is something they are very, they’re happy about. They were not happy with their overeating and they see themselves losing weight. For most of them, they’re very happy about that. But, for some patients, that can be stressful because the operation itself has taken away something that was, at one time, a comfort for them and they have to find some other ways to mitigate that.
Melanie: Are there certain things you’d like them to do before the surgery?
Dr. Stahl: Yes. So, all of our patients undergo a very expensive preoperative education. Our patients, if they’re interested in weight loss surgery, they’d first have a required reading that we send to them. That reading actually includes a little test at the end to make sure they’ve understood what they’ve read. And the reading is about the goals and risks of bariatric surgery and an overview of bariatric surgery. We then have them watch a video before they come to see us. Then, they come to see us. And their first visit is actually most of an afternoon of which a good part of that time is spent in a classroom with yet more teaching about weight loss surgery. That would followed by a standard history and physical where we’re trying to determine if we think they are medically fit to undergo surgery. Assuming that they are, then we put them into our program where they will have some standard preoperative labs done. If they may or if they are having a gastric bypass or sleeve gastrectomy, we may have them undergo a barium upper GI or an upper endoscopy prior to surgery. We may have them go through psychologic testing. That is not done in every individual but is done either based on their insurance requirements or their medical history. And, they go through a series of nutrition education classes teaching about both the diet that we place them on immediately prior to surgery as well as the diet progression they’ll be on after surgery and the vitamins and micronutrient supplementation that will be necessary for them for life afterwards. So, primarily it is, there’s a lot of education that these patients go through, probably more so for this operation than any other operation that we do.
Melanie: And, as it is a tool for weight loss, Dr. Stahl, what is your preferred method with the best outcomes of the types of surgery available?
Dr. Stahl: The two operations that we do most commonly are laparoscopic gastric bypass and laparoscopic sleeve gastrectomy. We at UAB have seen an evolution of the sleeve gastrectomy over time becoming more popular with patients. That has occurred, not just at UAB, but across the nation where sleeve gastrectomy is now the most commonly performed weight loss operation in the US. Now, I don’t want to misinform or say that that is a, because it is a better operation. It is a more popular operation. When we talk about outcomes, we have to really discuss not just weight loss outcomes but treatment of comorbidities such as diabetes, dyslipidemia, sleep apnea syndrome, et cetera, so the other comorbidities that go along with the operation as well as complications and problems that may occur related to the operations. So, in that regard, we have far more experience with gastric bypass than we do with sleeve gastrectomy simply because it has been around for a lot longer. So, we have much more or a larger number of patients that have had gastric bypass in the country than have had sleeve gastrectomy and they’ve been followed for a much longer period of time, so we have a better understanding of the long term outcomes with gastric bypass. Even though we currently actually perform, on a yearly basis, more sleeve gastrectomy than we do bypass. The gastric bypass and sleeve gastrectomy compare fairly. They have fairly similar results in terms of weight loss. There are some studies that would suggest that gastric bypass may have a moderately better weight loss results than the sleeve gastrectomy but that still is not entirely known yet and is still being studied. Likewise, gastric bypass seems to have somewhat better results for the treatment of diabetes than sleeve gastrectomy in some studies. But, that’s not been in all studies. So, that data is still being gathered. The sleeve gastrectomy probably has a little bit lower risk profile, tends to have somewhat less chance of complications than the gastric bypass, though not markedly so. And, the risk of vitamin or micronutrient deficiencies later on is probably a little less with the sleeve gastrectomy than it is with the gastric bypass. So, as you can see, there really are pros and cons to both operations. Neither of them are perfect; neither of them are a panacea. They both have potential risks and complications. We go over all of that extensively with patients and, for the most part, allow the patients to choose but what we insist on is they have to be making an informed decision. So, that’s what we really are very keen on--preoperative education for the patients.
Melanie: What are some complications that you like your team to be well aware of? Infection rates at surgical site or leaking from the pouch? What is it you’re looking for post-surgery?
Dr. Stahl: So, both of the operations, sleeve gastrectomy and gastric bypass, have as one of their risks a leak--a leak from the area where the stomach was resected in a sleeve gastrectomy or a leak from the anastomosis between the stomach and the intestine or the further downstream anastomosis in a gastric bypass. Risk of leaks is less than one percent in both of those operations. But, those are very potentially serious complications. Other risks include blood clots such as DVT or a pulmonary thromboembolus. Again, that’s less than one percent, probably less than one half of one percent in both of those operations. And then, there are risks of surgical site infections. So, those are actually fairly small. Since we do most of these operations laparoscopically, the incisions that we make are quite small, and since they are small incisions, the risk of surgical site infection is quite low in both of these operations. There are, of course, risks of vitamin and micronutrient deficiencies that I mentioned earlier and some potential long-term complications such as bowel obstruction or even malnutrition, which is quite rare but can occur.
Melanie: What are you looking for post-surgery as far as the patient is concerned? Depression post-surgery? Or, what do you tell them also about excessive skin and dealing with that?
Dr. Stahl: So, with depression, yes, that goes back to that preoperative education and counseling to let the patients know that in undergoing weight loss surgery that patient may be losing a coping mechanism. So if they were one, a patient that ate because of stress or depression, whatever it be, that will be lost to them. And, if they were a stress eater, so to speak, undergoing surgery may actually even increase their stress because they can no longer cope with it the way they used to. So, it’s important for those patients to have ongoing psychologic counseling. On the other hand, the more common occurrence is patients might have some degree of depression that is related to their obesity in the first place and treating the obesity tends to make the depression get better. So, we actually see more patients with improvement in their mental outlook and improvement in their depression than augmentation of it, though both can occur. Your second question in regards to excess skin, for most individuals, that is not a problem but there are some where it will be. So, for instance, our body is very good at growing additional skin to cover a surface. So, if someone gains weight and gets obese over the years, their skin will gradually grow to cover all of that fatty tissue underneath it. When we lose weight, we’re losing the fat cells or we’re losing the fat within those cells underneath the skin, but we’re not losing the skin itself. So, we’re good at growing new skin. We’re not good at getting rid of skin, our bodies. For most individuals, there’s enough elasticity to the skin that the skin will shrink somewhat and while they may have some excess skin, it tends not to be much of a problem. But, for some patients, they can lose quite a lot of weight and may have a rather extensive skin folds that then would be perhaps unsightly and sometimes even cause ulcerations in the skinfold, et cetera. Those patients can undergo plastic surgery, cosmetic surgery, to remove those skin folds. Unfortunately, insurance doesn’t cover that much of the time. Some insurance policies do cover it under very special circumstances, but not all insurance companies cover that. We usually will refer those patients to plastic surgery for consideration of surgical treatment and body contouring, et cetera, though we do ask for the patients to wait until they’ve reached a new body weight where they’ve plateaued. And, that’s typically sometime between eighteen months to two years before we would recommend they undergo plastic surgery for that.
Melanie: Dr. Stahl, are there some clinical trials you’d like to discuss?
Dr. Stahl: Oh, there are a number of clinical trials that are going on around the country; none in particular that we have here. We follow several of them and we have some other research projects that are dealing more with the metabolism associated with weight loss surgery and the microbiome that exists--the bacteria that exist within the GI tract and the bacterial content that actually changes with weight changes. We are doing some studies on that where some of our patients will volunteer or are enrolled for that, then collect specimens from them to check their microbiome and all. But, yes, we follow an awful lot of other studies that are out there as well.
Melanie: And, in the last few minutes, Dr. Stahl, how can a community physician refer a patient to UAB medicine?
Dr. Stahl: The easiest way is to just call our office (205) 975-3000 and ask for information about weight loss surgery. They’ll direct you to one of our office personnel who then will get some information and we can get an information package out in the mail to that patient; either in the mail or we can give them our website address where they can download that information. That’s the starting point. Once they get the information packet, we would have them read that and they fill out some demographic information and send it back to us. And, that starts the process and we would take over from there.
Melanie: And, tell us about your team. Why is UAB so great to work with?
Dr. Stahl: Oh, you know, well, number one, the folks that I work with here are terrific. They are a dedicated group of individuals and very dedicated to the care of the obese patient and dealing with metabolic illness associated with obesity. You know, UAB, we’re a tertiary care center. We for, better or ill, we’re the point where when people, if they have complications or problems elsewhere, they frequently end up here at UAB. So, we have quite a large experience in taking care of complicated problems. So, for that reason, we actually think we’re probably a really good starting point for patients that are considering weight loss surgery since we tend to take care of some of the most complicated problems associated with it. Well, we just assume, take care of them right from the get go here.
Melanie: Thank you so much, Dr. Stahl, for being with us today. You're listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to www.uabmedicine.org/physician. That's www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): Bariatric surgery is indicated for patients who are morbidly obese and already have tried diets, exercise, and other non-surgical means of losing weight. The bariatric surgery program at UAB Medicine has been performing weight loss procedures for more than thirty years and it is the first American College of Surgeons Level 1 Bariatric Surgery Center in Alabama. My guest today is Dr. Richard Stahl. He’s the medical director of Bariatric Surgery at UAB Medicine. Welcome to the show, Dr. Stahl. So, let’s start with some parameters for consideration of bariatrics. When a patient comes to you, what are you looking for?
Dr. Richard Stahl (Guest): The criteria that we use are still based on the National Institute of Health Criteria that were set back in 1991. Patients with a body mass index of 40 or above would qualify for bariatric surgery regardless of comorbidities. Patients with a body mass index between 35 and 39.9 would qualify for bariatric surgery if they have comorbidities that are obesity related.
Melanie: So, what about the psychological aspect? And, what do you tell your patients about dealing with the aspects of this surgery?
Dr. Stahl: You’ve touched on a very good point. For many patients that are undergoing bariatric surgery or that are considering bariatric surgery, they may have some psychologic issues such as depression. And, oftentimes those psychologic issues might be related to their weight. In other words, their weight is driving that particular emotion or problem that they're having and, therefore, treatment of their weight often times improves that. We don’t see psychologic pathology in obese patients at a higher rate than we do in non-obese patients other than obese patients do have a somewhat higher rate of depression, though that seems to be due to their obesity. In addition, for patients undergoing weight loss surgery, they are sometimes losing what was for them a coping mechanism. By that I mean, some patients eat, perhaps overeat, perhaps because they’re stressed. Sometimes we overeat because we’re happy; sometimes because we’re sad; sometimes we overeat because we’re lonely; any number of reasons why we might overeat. And, once you undergo weight loss surgery, that particular coping mechanism (i.e. overeating) has been taken away from you. Now, for many patients, that is something they are very, they’re happy about. They were not happy with their overeating and they see themselves losing weight. For most of them, they’re very happy about that. But, for some patients, that can be stressful because the operation itself has taken away something that was, at one time, a comfort for them and they have to find some other ways to mitigate that.
Melanie: Are there certain things you’d like them to do before the surgery?
Dr. Stahl: Yes. So, all of our patients undergo a very expensive preoperative education. Our patients, if they’re interested in weight loss surgery, they’d first have a required reading that we send to them. That reading actually includes a little test at the end to make sure they’ve understood what they’ve read. And the reading is about the goals and risks of bariatric surgery and an overview of bariatric surgery. We then have them watch a video before they come to see us. Then, they come to see us. And their first visit is actually most of an afternoon of which a good part of that time is spent in a classroom with yet more teaching about weight loss surgery. That would followed by a standard history and physical where we’re trying to determine if we think they are medically fit to undergo surgery. Assuming that they are, then we put them into our program where they will have some standard preoperative labs done. If they may or if they are having a gastric bypass or sleeve gastrectomy, we may have them undergo a barium upper GI or an upper endoscopy prior to surgery. We may have them go through psychologic testing. That is not done in every individual but is done either based on their insurance requirements or their medical history. And, they go through a series of nutrition education classes teaching about both the diet that we place them on immediately prior to surgery as well as the diet progression they’ll be on after surgery and the vitamins and micronutrient supplementation that will be necessary for them for life afterwards. So, primarily it is, there’s a lot of education that these patients go through, probably more so for this operation than any other operation that we do.
Melanie: And, as it is a tool for weight loss, Dr. Stahl, what is your preferred method with the best outcomes of the types of surgery available?
Dr. Stahl: The two operations that we do most commonly are laparoscopic gastric bypass and laparoscopic sleeve gastrectomy. We at UAB have seen an evolution of the sleeve gastrectomy over time becoming more popular with patients. That has occurred, not just at UAB, but across the nation where sleeve gastrectomy is now the most commonly performed weight loss operation in the US. Now, I don’t want to misinform or say that that is a, because it is a better operation. It is a more popular operation. When we talk about outcomes, we have to really discuss not just weight loss outcomes but treatment of comorbidities such as diabetes, dyslipidemia, sleep apnea syndrome, et cetera, so the other comorbidities that go along with the operation as well as complications and problems that may occur related to the operations. So, in that regard, we have far more experience with gastric bypass than we do with sleeve gastrectomy simply because it has been around for a lot longer. So, we have much more or a larger number of patients that have had gastric bypass in the country than have had sleeve gastrectomy and they’ve been followed for a much longer period of time, so we have a better understanding of the long term outcomes with gastric bypass. Even though we currently actually perform, on a yearly basis, more sleeve gastrectomy than we do bypass. The gastric bypass and sleeve gastrectomy compare fairly. They have fairly similar results in terms of weight loss. There are some studies that would suggest that gastric bypass may have a moderately better weight loss results than the sleeve gastrectomy but that still is not entirely known yet and is still being studied. Likewise, gastric bypass seems to have somewhat better results for the treatment of diabetes than sleeve gastrectomy in some studies. But, that’s not been in all studies. So, that data is still being gathered. The sleeve gastrectomy probably has a little bit lower risk profile, tends to have somewhat less chance of complications than the gastric bypass, though not markedly so. And, the risk of vitamin or micronutrient deficiencies later on is probably a little less with the sleeve gastrectomy than it is with the gastric bypass. So, as you can see, there really are pros and cons to both operations. Neither of them are perfect; neither of them are a panacea. They both have potential risks and complications. We go over all of that extensively with patients and, for the most part, allow the patients to choose but what we insist on is they have to be making an informed decision. So, that’s what we really are very keen on--preoperative education for the patients.
Melanie: What are some complications that you like your team to be well aware of? Infection rates at surgical site or leaking from the pouch? What is it you’re looking for post-surgery?
Dr. Stahl: So, both of the operations, sleeve gastrectomy and gastric bypass, have as one of their risks a leak--a leak from the area where the stomach was resected in a sleeve gastrectomy or a leak from the anastomosis between the stomach and the intestine or the further downstream anastomosis in a gastric bypass. Risk of leaks is less than one percent in both of those operations. But, those are very potentially serious complications. Other risks include blood clots such as DVT or a pulmonary thromboembolus. Again, that’s less than one percent, probably less than one half of one percent in both of those operations. And then, there are risks of surgical site infections. So, those are actually fairly small. Since we do most of these operations laparoscopically, the incisions that we make are quite small, and since they are small incisions, the risk of surgical site infection is quite low in both of these operations. There are, of course, risks of vitamin and micronutrient deficiencies that I mentioned earlier and some potential long-term complications such as bowel obstruction or even malnutrition, which is quite rare but can occur.
Melanie: What are you looking for post-surgery as far as the patient is concerned? Depression post-surgery? Or, what do you tell them also about excessive skin and dealing with that?
Dr. Stahl: So, with depression, yes, that goes back to that preoperative education and counseling to let the patients know that in undergoing weight loss surgery that patient may be losing a coping mechanism. So if they were one, a patient that ate because of stress or depression, whatever it be, that will be lost to them. And, if they were a stress eater, so to speak, undergoing surgery may actually even increase their stress because they can no longer cope with it the way they used to. So, it’s important for those patients to have ongoing psychologic counseling. On the other hand, the more common occurrence is patients might have some degree of depression that is related to their obesity in the first place and treating the obesity tends to make the depression get better. So, we actually see more patients with improvement in their mental outlook and improvement in their depression than augmentation of it, though both can occur. Your second question in regards to excess skin, for most individuals, that is not a problem but there are some where it will be. So, for instance, our body is very good at growing additional skin to cover a surface. So, if someone gains weight and gets obese over the years, their skin will gradually grow to cover all of that fatty tissue underneath it. When we lose weight, we’re losing the fat cells or we’re losing the fat within those cells underneath the skin, but we’re not losing the skin itself. So, we’re good at growing new skin. We’re not good at getting rid of skin, our bodies. For most individuals, there’s enough elasticity to the skin that the skin will shrink somewhat and while they may have some excess skin, it tends not to be much of a problem. But, for some patients, they can lose quite a lot of weight and may have a rather extensive skin folds that then would be perhaps unsightly and sometimes even cause ulcerations in the skinfold, et cetera. Those patients can undergo plastic surgery, cosmetic surgery, to remove those skin folds. Unfortunately, insurance doesn’t cover that much of the time. Some insurance policies do cover it under very special circumstances, but not all insurance companies cover that. We usually will refer those patients to plastic surgery for consideration of surgical treatment and body contouring, et cetera, though we do ask for the patients to wait until they’ve reached a new body weight where they’ve plateaued. And, that’s typically sometime between eighteen months to two years before we would recommend they undergo plastic surgery for that.
Melanie: Dr. Stahl, are there some clinical trials you’d like to discuss?
Dr. Stahl: Oh, there are a number of clinical trials that are going on around the country; none in particular that we have here. We follow several of them and we have some other research projects that are dealing more with the metabolism associated with weight loss surgery and the microbiome that exists--the bacteria that exist within the GI tract and the bacterial content that actually changes with weight changes. We are doing some studies on that where some of our patients will volunteer or are enrolled for that, then collect specimens from them to check their microbiome and all. But, yes, we follow an awful lot of other studies that are out there as well.
Melanie: And, in the last few minutes, Dr. Stahl, how can a community physician refer a patient to UAB medicine?
Dr. Stahl: The easiest way is to just call our office (205) 975-3000 and ask for information about weight loss surgery. They’ll direct you to one of our office personnel who then will get some information and we can get an information package out in the mail to that patient; either in the mail or we can give them our website address where they can download that information. That’s the starting point. Once they get the information packet, we would have them read that and they fill out some demographic information and send it back to us. And, that starts the process and we would take over from there.
Melanie: And, tell us about your team. Why is UAB so great to work with?
Dr. Stahl: Oh, you know, well, number one, the folks that I work with here are terrific. They are a dedicated group of individuals and very dedicated to the care of the obese patient and dealing with metabolic illness associated with obesity. You know, UAB, we’re a tertiary care center. We for, better or ill, we’re the point where when people, if they have complications or problems elsewhere, they frequently end up here at UAB. So, we have quite a large experience in taking care of complicated problems. So, for that reason, we actually think we’re probably a really good starting point for patients that are considering weight loss surgery since we tend to take care of some of the most complicated problems associated with it. Well, we just assume, take care of them right from the get go here.
Melanie: Thank you so much, Dr. Stahl, for being with us today. You're listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to www.uabmedicine.org/physician. That's www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.