Surgical weight-loss options: What to expect
[00:00:00] Host Amber Smith: From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." If you are someone who has struggled to lose a significant amount of weight, you may have wondered whether surgery was an option. I'm talking with Dr. Lauren Rabach, who leads the metabolic and bariatric surgery program at Upstate, and we'll be covering who qualifies and what he or she can expect from weight-loss surgery.
[00:00:23] Host Amber Smith: Dr. Rabach, thank you so much for taking time to talk about this with "HealthLink on Air."
[00:00:28] Lauren Rabach, MD: Thank you for having me.
[00:00:29] Host Amber Smith: Now, who is the ideal candidate for weight-loss surgery?
[00:00:34] Lauren Rabach, MD: So, the ideal candidate for weight-loss and bariatric surgery is one that's motivated.
[00:00:40] Lauren Rabach, MD: One that wants to really make a difference and an impact in their current lifestyle, whether that is getting off of certain medications, not wanting to take any further insulin or be on a CPAP machine for sleep apnea. So those are patients that we would recommend looking further into bariatric surgery.
[00:00:58] Lauren Rabach, MD: Patients who qualify have to have a certain BMI cutoff or body mass index, and that is a BMI greater than 40 if you don't have any other related medical conditions or a BMI of 35 with those medical conditions associated with obesity. And that can be anything from high blood pressure to type 2 diabetes to osteoarthritis and joint pain, high cholesterol, sleep apnea. There's about 15 associated diagnoses that qualify, and actually the Society of Metabolic and Bariatric Surgery have correlated almost 40 disease processes that are directly associated with obesity.
[00:01:38] Host Amber Smith: Are there any issues that might disqualify someone from weight-loss surgery?
[00:01:43] Lauren Rabach, MD: It's very individualized. We take a look at the whole patient, what other medical conditions they have, what prior surgeries and current medication list that they'll need to take moving forward with their medical problems, so I'd say there aren't any true, hard contraindications, but we do have a multidisciplinary team to look at the patient as a whole, so from all organ systems, from a mental health standpoint, are they safe and optimized to undergo that surgery?
[00:02:11] Lauren Rabach, MD: And that's really the goal before offering them a date (to undergo surgery).
[00:02:14] Host Amber Smith: Is weight-loss surgery an option for someone who wants to treat their diabetes?
[00:02:20] Lauren Rabach, MD: Yes, it is. Weight-loss surgery is probably the best tool we have for treatment of diabetes. We've looked at this in big, large studies.
[00:02:28] Lauren Rabach, MD: The Swedish obesity study is probably the biggest one to date, and it compares bariatric surgery to just diet and exercise alone in terms of the percent of resolution at one year, five years, 10 years down the road. And you're looking at a much higher rate of resolution, over three times as high, in patients with bariatric surgery, and especially with the gastric bypass.
[00:02:51] Host Amber Smith: So, someone who has diabetes, do they have to be obese also in order to have this same procedure?
[00:02:59] Lauren Rabach, MD: They do. They need to have a BMI of greater than 35, a body mass index, at present time based on what the requirements are for their particular insurance.
[00:03:09] Host Amber Smith: So once somebody is thinking about surgery and has come to see someone like yourself, what else happens?
[00:03:17] Host Amber Smith: What else do patients need to do before they have the operation?
[00:03:22] Lauren Rabach, MD: You know, I think first starting with talking to their primary care doctors or providers that they feel very close with to kind of have a conversation, with their goals, with losing weight and getting healthier.
[00:03:37] Lauren Rabach, MD: I think a good support system from family, from friends, is important. And then from there, what they can expect is a full examination, not only their heart and lungs, but also mental health. So we have them evaluated by our psychologists, our dieticians, their primary care providers, as well as myself and the other surgeons in the group to see, are they healthy and ready for a big bariatric surgery, such as a Roux-en-Y gastric bypass or sleeve.
[00:04:06] Lauren Rabach, MD: So, they meet with a support group at least one time. And this support group is really run by our coordinators, but also a big role in this support group is prior patients who have had successes or patients that are going through the pipeline.
[00:04:21] Lauren Rabach, MD: And so this is a good group for more information and more resources that come from other people such as our coordinator, our nurses, and other people who have experienced the surgery. We also would like to see some demonstration of weight loss, but again, that's very individualized, and oftentimes we don't give the patients preoperatively a number that they have to hit.
[00:04:42] Lauren Rabach, MD: It's more the small changes that they're making to their lifestyle, to their activity, to their diet. So then afterwards, they're the most successful with their weight loss. Education is a very, very big component to what we do to what we offer to these patients. More so than the surgery. The surgery is just a very small piece to the puzzle for them to be successful.
[00:05:02] Host Amber Smith: This is Upstate's "HealthLink on Air." I'm your host, Amber Smith, speaking with Dr. Lauren Rabach. She leads the metabolic and bariatric surgery program at Upstate, which has a robust web presence at upstate.edu/bariatric. We've covered who qualifies for weight-loss surgery. And now we're going to look more closely at the types of surgery available and what patients can expect.
[00:05:23] Host Amber Smith: So, Dr. Rabach, can you describe the different types of surgeries?
[00:05:28] Lauren Rabach, MD: Absolutely. So, the two most popular surgeries that we do currently, the sleeve gastrectomy, and that is where we remove about 80% to 85% of the patient's stomach. And this works in a couple ways, so you are going to have that restrictive effect in which you can't eat as many calories or consume as much as you would have prior to the surgery.
[00:05:50] Lauren Rabach, MD: But we think, more importantly, what really drives weight loss after this is what we call the metabolic effect. So you have changes in your hormones that interact between your stomach and that interact between your brain that are altered after this surgery. We think this is really important for driving weight loss and really promoting, like I said, the metabolic effect in those appetite hormones being very suppressed.
[00:06:12] Lauren Rabach, MD: The second common surgery that we do is called the Roux-en-Y gastric bypass.
[00:06:17] Lauren Rabach, MD: Now both of these surgeries that I'm talking about are performed in the minimally invasive approach, so small incisions. Patients tend to go home about a day after that surgery. With the gastric bypass, it's similar in that you're creating a smaller pouch from their normal size stomach, but you're also bringing up a piece of their small intestine. In that way, food is traveling in a different orientation than where it was before, so it will bypass and that's where we get the word gastric bypass, the first portion of your small intestine, called your duodenum. And this is very important also for the metabolic effect, which is similar to the sleeve gastrectomy, but what's even more important about it is the ability to bypass that first portion of the small bowel really makes a huge difference in terms of the ability to increase the amount of insulin that we're secreting, but also decreasing our insulin resistance, which helps with diabetes long term.
[00:07:14] Lauren Rabach, MD: And there's a direct effect on glycemic control, and like I mentioned before, the appetite hormones. So, we know about ghrelin and incretin, and we also know about GLP-1, and these hormones are directly altered after these surgeries. And you can see these alterations up to even five, 10 years after, when we do look at these patients and the levels of their hormones afterwards.
[00:07:34] Lauren Rabach, MD: So that's the biggest difference when you compare these two surgeries that we perform, and you look at that with diet and exercise. And so those two surgeries are the most common ones that we do today.
[00:07:44] Lauren Rabach, MD: The gastric band was one that we had performed, I'd say, in the '90s and early 2000s. It was a very popular surgery. Today, we tend to see patients who have them and more often than not, we are removing these bands and offering revisional surgery for those patients. These bands were really popular because they provided that restrictive effect. So the band goes around your stomach and is inflated so that when it's inflated with more water, that inflation tightens around your stomach, and so you have that restriction, and you can't eat as much. But what we found was, it's only providing restriction and not that metabolic effect, such as the gastric sleeve and the bypass provides. And so that's why we've kind of gone away from the gastric band and are really offering the sleeve and the bypass at higher rates, for the best long-term outcomes.
[00:08:35] Host Amber Smith: So, looking at the gastric sleeve and the gastric bypass, I'm curious which one is the safer option, which one lasts longer, and how do you go about helping a patient decide which one is the right one for them?
[00:08:49] Lauren Rabach, MD: Amber, that's a really good question, and a common one that I get asked when I meet with patients.
[00:08:54] Lauren Rabach, MD: So it really comes down to looking at the patient as a whole, and I bring that up time and time again, because everyone's an individual and comes with different medical conditions and a different background. So we kind of see what their prior history was with surgeries, with medical history.
[00:09:10] Lauren Rabach, MD: We also look at, you know, what medications they're going to need to be on long term, and so that will play a role into which surgery is best for who. Now, after we go through the process of making sure you're ready for surgery, the necessary lab work and testing, we then meet as a team.
[00:09:28] Lauren Rabach, MD: And that team is the patient, myself, our dietitians, because this really is a team decision. And at the end of that, we decide on what operation is best for that individual. Now comparing risks associated with the sleeve and the bypass, they're actually very similar. They have very low risks of complications and side effects.
[00:09:49] Lauren Rabach, MD: Especially in the year 2021, we've really done a lot of advancements as far as lowering our complication rates and getting patients out safely at that one day post-op mark and getting them back to doing their normal activities by about seven to 10 days. So low complication rates, similar complication rates between the surgeries that we offer, and patients tend to stay a similar length of time, about a day after surgery.
[00:10:15] Lauren Rabach, MD: The amount of time it takes to perform the surgery is very similar. Their post-operative diet is also very similar in their recovery, so, patients tend to do well with both of them. Both the sleeve and the bypass have excellent long-term weight-loss results, excellent results in resolving patient's comorbid conditions, like high blood pressure, diabetes, high cholesterol, and these are high rates. I'm talking like 80%, 90% for a lot of these conditions. So it's quite significant and quite amazing that we're able to do this with such low risk to the patient.
[00:10:50] Host Amber Smith: Eighty to 90% of success that it stays for the long term, you mean?
[00:10:55] Lauren Rabach, MD: And we're able to resolve certain conditions.
[00:10:57] Lauren Rabach, MD: So we've looked at patients who've had both a sleeve and bypass and looked at how their success was at even five years after surgery, and patients who've had a sleeve or a bypass,their chance of getting off those medications, not needing their CPAP machine anymore for their sleep apnea is very high, and that's where I'm talking about 80%, 90%, sometimes 95% resolution rates, especially when you're looking at diabetes, high blood pressure, high cholesterol, we've really have excellent results with getting patients off of those medications for good.
[00:11:30] Host Amber Smith: So it sounds like you have a lot of patients whose lives have really been improved quite a bit by their surgery, not to mention they've also lost weight, but they've also improved their health status.
[00:11:41] Lauren Rabach, MD: I agree. Absolutely. It's not uncommon that the day after surgery, we're already taking them off their medications, high blood pressure medications. We're lowering their dosages of their insulin or their oral diabetes medications, even 24 hours after their surgery.
[00:11:56] Lauren Rabach, MD: And it continues, even weeks, months down the road, us trying to reduce their dosages or taking them off their medications in general..
[00:12:04] Host Amber Smith: Can you tell me, once the patient has a surgery date on the calendar, how do you tell them to prepare for that? What do they need to do to get ready?
[00:12:13] Lauren Rabach, MD: By the time they have their surgery date, they're already very well prepared. So they've met with me or one of the surgical providers, they've met with our dietitians on a pretty consistent basis, at least once a month, where we talk about the educational component, which is very key. So the diet to expect, activity level that we'll want them to participate in as soon as they're done, the vitamins that they're going to have to start taking shortly after the surgery.
[00:12:40] Lauren Rabach, MD: All of these things we've talked about, and the patients have their expectations very clear by the time that surgery date rolls around. And then after that, it's really just about implementing those small changes, so that they're very successful with their weight loss long term making sure that they're really hitting their goals, that they're getting the necessary lab work and meeting with the necessary providers to make sure that they're on track.
[00:13:02] Host Amber Smith: So, it sounds like, even before the operation, the patient kind of starts living the life they're going to be living after the operation. They have to be prepared for that and used to it so that it's not like they come into the hospital and have the operation, and it's a whole different world when they leave. They're already accustomed to what they're going to have to eat and how they're going to have to behave.
[00:13:26] Lauren Rabach, MD: Exactly. It's a, you know, it's a very powerful tool that we have, but at the end of the day, it's a long journey, and they're gonna have ups and downs, and there's going to be days where they take two steps forward and one step back. And so having all of that education before the surgery, it makes it an easier transition for them when they have to go through such big changes during the surgery.
[00:13:49] Host Amber Smith: Well, I want to thank you so much for taking time out of your schedule to help explain all of this to us.
[00:13:53] Host Amber Smith: My guest has been Dr. Lauren Rabach. She's a surgeon who leads the metabolic and bariatric surgery program at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."