Joey Wahler (Host): It can dramatically improve someone's health, but it's not a cure all by itself. So, we're discussing weight loss surgery. Our guest, Dr. Peter Lalor, Medical Director and Bariatric Surgeon, Double Board-Certified in Obesity Medicine and General Surgery for Wood County Hospital.

This is Health Matters: Insights from WCH Medical Experts. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. Lalor. Welcome.

Dr. Peter Lalor: Hi, nice to see you again, Joey.

Host: Absolutely, same here. So first, generally speaking, what's the profile? Who's a candidate for weight loss surgery?

Dr. Peter Lalor: So in medical-surgical terms, we use something called the body mass index, which is basically your weight over your height squared, and it gives you a number. And to qualify for weight loss surgery, your body mass index has to be between 35 and 40 with medical problems or a body mass index over 40 plus or minus medical problems. But in layman's terms, if you're about 100 pounds overweight, then you're actually going to qualify for weight loss surgery.

Host: Okay. So, what are the options these days for weight loss surgery and how exactly do they work?

Dr. Peter Lalor: There's been a number of options over the years. There's the adjustable gastric band or the lap band, which was very popular for a while, it's gone out of favor. There's the sleeve gastrectomy, which has become the most popular surgery. The classic Roux-en-Y gastric bypass, which has been around for decades. And there's even a very dramatic bypass called the biliopancreatic diversion with duodenal switch. But these days, in this country, it comes down to basically sleeve gastrectomy and gastric bypass. Now, these are both surgeries, major surgeries, where we're operating on your gastrointestinal tract, your stomach, and sometimes your intestines.

So for the sleeve gastrectomy, what we actually do is go in from a minimal invasive approach, some keyhole surgery. We actually go up into your stomach, and we remove 75% of the side of your stomach. We literally take it out of the body and send it to the lab, and what you're left with is a stomach that's the size of about a banana or a sleeve, as we named it. The capacity of this stomach is about 80 to 100 cc, so that's all you can eat or drink at one point. So you're very restricted to how much food you can take in at one point. But also, by removing the side of your stomach, with it comes a lot of appetite-stimulating hormones that we call ghrelin. So, we're actually removing a lot of the physical appetite so that when you do eat, you can't eat very much and you don't feel like eating anyway. And that gives a significant amount of weight loss.

Now, the other surgery that's still the most popular surgery with the sleeve gastrectomy is the Roux-en-Y gastric bypass. And this works by making your stomach smaller, so we make your stomach into a small little pouch. But in this surgery, we don't take anything out, but we actually rearrange your intestines so whatever you do eat doesn't get absorbed 100%. So, you have a stomach the size of a shot glass or a pouch. And that's all you can eat or drink at one time. But also, once that food is eaten or drank, instead of going to the old stomach to be digested as normal, it bypasses the first few feet of your intestines in your old stomach and it's not exposed to digestive enzymes very much until about 20%, a couple feet down the line, it's then exposed to all the digestive enzymes. And from that point, absorption is normal, but this combination of making your stomach smaller and adjusting the absorption of what you do eat contributes to significant weight loss over time.

Host: And hence the term bypass, right?

Dr. Peter Lalor: Yeah, it actually bypasses the old stomach. So, we literally divide your stomach into two parts. Again, we don't take out the old stomach. It's still there. It still growls. It still makes acid. It still makes enzymes. But it never sees food. And all those digestive enzymes and acids that are made there, they still drain normally. But again, they don't meet up with the food until a couple feet down the line.

Host: Interesting. So, that being said, how do you and your patients go about determining which of those is the best option in their particular case?

Dr. Peter Lalor: That's a great question. Actually, you know, it depends on a number of factors. It has to depend on what the patient is comfortable with. Although these are both invasive surgeries, some people don't like the idea of taking out part of their stomach with a sleeve gastrectomy and other people look at the pictures of gastric bypass, and all that rearranging looks very foreign to them.

But from our standpoint, what we're looking at really is the medical problem profile. There are some medical problems that will respond better to others. For instance, if someone's on insulin and has really bad insulin dependent diabetes, the gastric bypass has been shown metabolically to work better to fight their diabetes than, say, the sleeve. On the flip side of that, if a patient has really bad reflux or heartburn symptoms, they might not want to do the sleeve gastrectomy because their reflux might get worse and maybe the bypass might be better for them as well. It really depends on the patient's, what we call, comorbid profile to what we recommend which surgery.

Host: How about the risks? I mean, whether we're talking about rearranging your insides or removing a large portion of them, it sounds drastic.

Dr. Peter Lalor: Yeah. I mean, surgery is by nature invasive. But these days in 2024, we've gotten very slick at the procedures. Everything is minimal invasive through a few small incisions, very similar to getting your gallbladder out or getting a knee scope done. It's the same type of little incisions. The complication rates have dropped significantly over the years to make this a very realistic option for the right candidate.

Every surgery has complications. The biggest complications from these surgeries are what we call a leak, which is where there's infection that leaks from the staple line or where we hook things up. The risk of this is probably less than 1%. So again, it's something that we have to keep in the back of our minds, but it's not a reason not to do the surgery.

The other major risks that we see are sometimes more on the medical side. Blood clots, because if someone is morbidly obese, they have a risk factor to get a blood clot, whether they undergo any surgery, let alone these. And if they were to get a massive blood clot, that could be life-threatening as well. But again, the risk of this is less than 1%. So, it has its complication rates, but we've been able to minimize it over time to make it a realistic option. And when you compare it to other surgeries, like I mentioned, it's very similar.

Host: So, it sounds more drastic than it is, is really the bottom line there, right?

Dr. Peter Lalor: Yeah, I mean, it's a big commitment. The patient has to be ready to make the lifestyle changes this requires, and eating differently, and attempting to exercise and take vitamins in some cases long term. But yes, we've gotten very good at it to really minimize that risk in most patients.

Host: And you led me perfectly into my next query, which is, how about those other lifestyle changes we alluded to at the top? It's not just about surgery, there's more of a job on the part of the patient that goes along with it, particularly afterward.

Dr. Peter Lalor: Yeah. And that's an important point when someone's thinking about these surgeries. The education component before surgery is extremely important. They need to know what they're getting themselves into. Not just from a complication and risk standpoint, but what their diet is going to require and sometimes even supplementation. So, you know, we teach patients how to eat, how to think about food, how to count protein calories, amounts, and using small plates, using small spoons, chewing your food well to make yourself successful later on. But ultimately, the patient's success is going to depend on their adherence to those protocols postoperatively. If a patient sticks to what they've been taught and educated on to do the right things, they have a much better chance of being successful in the long term. But unfortunately, if they don't change, and they're not willing to participate and change what they're doing, they're not likely to be successful long-term, even with something as invasive as surgery.

Host: What in essence are the responsibilities of a weight loss surgery patient post-op?

Dr. Peter Lalor: Well, I think, the easiest thing to say is they need to follow the guidelines. A reasonable diet program. And it's not really a diet. It's just a way of eating. It's really no different than we would tell anybody now, a low fat, low carbohydrate, high protein diet in small amounts. That's really the dietary instructions. So, these patients, even after surgery, have a large variety of things they can eat. They're just not supposed to eat them in large amounts, or or certainly they can't at the beginning. But the patient still has to portion control and attempt to follow these rules.

Host: You mentioned the importance of patients being aware of all this going in so that obviously there won't be any surprises on the other end. How important is that, doctor? How important is the mental aspect here? Just being aware that they're going to have to take control of their own life in certain ways that they haven't in the past in order for the surgery to be fully effective, right?

Dr. Peter Lalor: Yeah. Believe it or not, most people think about surgery for at least a year before they come see me. And so, that thought process or to let things process over time is really important. We also don't rush people to surgery. Weight loss surgery programs are a minimum of three to six months preparation for surgery where we're talking about the risks, we're talking about the lifestyle changes, the diet, the exercise, the vitamins, all the things that they have to be successful with, lose the weight they want. And it hopefully sinks in over this minimum of three-month period. We also actually have them see a psychologist to make sure that they understand what they're getting themselves into and that there's no red flags that are going to get in the way of their success.

Host: Interesting that they also see someone on the mental side as well. A few other things. First, what results can patients expect? I'm sure that's the big question people ask when they're talking with you about this. Weight loss surgery is going to do what ideally for people once it's all over with and they're sticking to what they need.

Dr. Peter Lalor: Yeah. I mean, obviously a lot of people do this to improve their medical problems, but everyone wants to know how much weight are they going to lose, right? So, the average patient loses about two-thirds of what they need to lose. So if they're a hundred pounds overweight, the average patient's going to lose 65 to 70 pounds. And those are average numbers. That means that there are patients that achieve 80, 90, and rarely sometimes even a hundred.

Now, you know, we always tell patients the surgeries are not designed to get you to lose every single pound. But two-thirds of your weight on average is some pretty good numbers. And that really blows everything else out of the water, especially in the day and age where there's medications popping up and the shots and so forth. If you have that much weight to lose, none of that other stuff's going to do it like surgery is.

Host: And if you're losing two-thirds of your weight loss goal, it stands to reason that if you do what you're supposed to after surgery, it's going to be easier for you to try losing the rest, right?

Dr. Peter Lalor: Well, actually, that's not necessarily the case, Joey. Believe it or not, because of our genetics, the more weight we lose, the harder it is to lose more weight. We find that patients, they lose that first 20 or 30 pounds literally in a couple of months, but trying to lose that last 20 or 30 pounds to get from 70% to 90% becomes harder and that's just our genetics and so forth. It's not impossible, but it's certainly something that, you know, a patient can set a goal to, but we try to be very realistic with our patients.

Host: And so, having said that, the fact that it is harder to lose that remaining percentage after surgery, what kind of support do you and yours offer to people trying to get over that last hurdle?

Dr. Peter Lalor: Yeah. And what you're talking really about is that psychological aspect, sticking into, you know, a regimen long-term, which can be very challenging. We encourage our patients to attend support groups and have a really good support network around them. It's important to involve their family and friends that can help keep them on track. And actually, the evidence is pretty clear that patients that attend support groups and have a good support network around them lose more weight than those who don't. So, that mental, psychological aspect and kind of family and friend involvement can be really important to the long-term success of a patient.

Host: I'm sure, absolutely. And so, finally, Doc, in summary here, what's next on the horizon when we talk about the future of Obesity Medicine? It seems like it's something we've all heard about our entire lives, right? There's always something coming down the pike. What's next do you think?

Dr. Peter Lalor: Well, I'm a big proponent to declare that obesity is a chronic disease that needs to be treated like other chronic diseases. There's a multimodal approach to it. And even though we've been talking about surgery, I think the long-term solution to fight this chronic morbid obesity disease is going to be surgery, which is going to give you a big chunk of weight loss upfront, as we've talked about two-thirds of your extra weight, but to help lose that last bit or to help people maintain what they've achieved, that's where the multimodal approach comes in, not just with diet exercise and the psychological game, but now there's even medications out there that even with surgery can help post-surgical patients either maintain or lose a little bit more weight.

And you've certainly probably heard about the shots, the GLP-1 agonists and so forth. So, not only do they have a role in medical weight loss on their own, but they actually play a role post-surgically sometimes in people that have had surgery in the mid to long term to help them be successful.

Host: Interesting. I was not aware of that. I presume the same is true of many people joining us. Folks, we trust you're now more familiar with weight loss surgery. Dr. Peter Lalor, thanks so much again.

Dr. Peter Lalor: Thanks, Joey.

Host: And for more information or to make an appointment, please call 419-373-7699. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. Thanks so much again for being part of Health Matters: Insights from WCH Medical Experts.