Minimally Invasive Weight Loss Surgery: Expert Q&A

Coming up on At
the Forefront Live, obesity is a very
challenging condition. People struggle with weight,
and are often frustrated with a lack of results. Today on At The
Forefront Live, we'll look at bariatric
surgery options, and how this can change lives. Here at UChicago Medicine,
bariatric surgery programs are tailored for each individual
to get the maximum outcome and benefit. Also today, we'll meet one
patient who lost over 80 pounds and gained control
over her diabetes. Lynn Yanow has quite
a story to tell, and is a different person today
because of bariatric surgery. That's next, on At
the Forefront Live. [MUSIC PLAYING] And welcome to
UChicago Medicine, At the Forefront Live. This is your chance to ask
our experts your questions by typing in the
comments section. We'll get to as many as possible
over the next half hour. Remember, this
program does not take the place of an actual
visit with your physician. Joining us today,
we have two experts in bariatric surgery, Dr.
Vivek Prachand and Dr. Mustafa Hussain. Welcome to the program. Thank you. First of all, just
tell us a little bit about bariatric
surgery, in general, what exactly that entails.

I think a lot of
people, when they think of bariatric surgery, they
think, you're just cheating, you're not dieting, you're
taking the easy way out. But that's really not the case. Thank you for the question. Bariatric surgery is
basically surgery– which means manipulation
of your organs and your stomach
and your intestine– to really change the way
your body perceives hunger and when it feels full. It works by changing
your anatomy, but also your physiology, which is the
chemical nature of your body's relationship and
understanding to food. And it works by mechanisms
that we partially understand, but not fully. And we're definitely
working on that. But it's definitely
not cheating. It is for people who have
tried several things before, but really need
additional help from us, in terms of losing weight. And it's really for
people who are looking to lose 75 or 100 pounds. So, Dr. Prachand,
why is it called obesity or metabolic surgery,
instead of weight loss surgery? I think that that's a
really good question, and I think it's
something that's really changed in the field
over the last 5 to 10 years. So the emphasis
used to really be about weight loss in the
past, and so we would really be emphasizing how many pounds
people lost, and so forth.

But the American
Medical Association, about five years ago,
recognized obesity as a disease. And one of the things
that we've always recognized with
these operations is that, in addition to achieving
the weight loss, which is pretty substantial
and sustainable, is the impact on the medical
problems related to obesity. And so the importance
of thinking about obesity and
metabolic surgery is to really keep in mind
and emphasize the fact that these operations
also have the opportunity to impact all the different
medical conditions that come along with obesity,
such as diabetes, high blood pressure, high
cholesterol, sleep apnea, severe joint problems. We even see patients who might
benefit from transplantation, but are too heavy to qualify
to undergo a transplant. Bariatric surgery can
really make a difference. We spoke to one patient who
had bariatric surgery here at UChicago Medicine,
and here's her story. And that has drastically
changed my life, not to have to
take insulin shots. I feel significantly better. Lynn Yanow was taking
four insulin shots a day. It was the only way she
could control her diabetes.

I feel better
emotionally, physically, and I'm very, very pleased. Now, Lynn is much lighter, and
off most of her medications, including those
four insulin shots. As of today, I've lost
80 pounds in six months. And I'm very excited about that. I would maybe like
to lose another 10, but everyone tells me
that I should leave it be. Lynn chose the bariatric
program at the University of Chicago Medicine,
one of the leading programs in the country. She had the gastric
bypass procedure, and is very happy
with the results. The reason that I chose
University of Chicago Medicine is because they had a
program, Dr. Hussein had a program to go
along with the bypass. You had to go to classes,
you had to follow up, there was a whole plan. What differentiates us
from everybody else is, I think, our experience,
our judgment, and our comprehensive
evaluation of patients.

UChicago Medicine offers
many options for weight loss. Some of those options
include surgery. There's sleeve gastrectomy,
gastric bypass, and a procedure for
extremely heavy patients– that is only done at about 1%
of the centers in the country– that's called the
duodenal switch. As an institution, we are
providing a wide array of options for patients who
are trying to lose weight, whether it's that 10 pounds you
need to lose after Christmas, or it's that 200 pounds that
you've accumulated over years. Each of these procedures
requires a team approach. The patient will work
with several caregivers to assess their challenges
and provide solutions.

There is also follow-up
after the procedure, to make sure the patient
has the right support to keep the weight off. So at a single
hospital visit, they will see the surgical
team, they will see our bariatric dieticians,
as well as our psychologist. And so it's a one-stop
shop, if you will. Weight loss isn't
easy, and the patients who participate in
the surgical program have struggled with their
situations for years prior. But the positive news
is there is hope, and it can be a lasting change. Despite all of our
biases, we don't know why people are overweight. It's easy to say they eat
more food than they actually burn off.

And while that may
be true, we don't understand why some patients are
more efficient at burning off food than others. Obesity is a complex issue. It has to do with your
genes, what you're eating, what your habits are, what
your social behavior is, what your psychological
situation is. So it's a complex issue, so it
doesn't have just one solution. Surgery happens to be
the most effective way to help people
lose weight, but we realize it doesn't
function in a vacuum. Lynn's family is happy
with her outcome, as well. It has changed her
life, and helped her to a healthier existence. Since I did the surgery, I
feel much better about myself. I am much more confident,
I do a lot more things. I do double-takes in
the mirror every time I walk a window, every time. I absolutely do not believe
that I look like this. And I feel very,
very good about it. It's an interesting story. And it's fascinating to hear
the difference in her life, particularly with her diabetes.

So to your point
just a moment ago, it really does make a
significant health difference. And one thing that
you touched upon in the video, Dr. Prachand– I wanted you to talk
maybe a little bit more about this– is
that overall plan. It's not just surgery, but
there are many different aspects and different things that people
go through before the surgery and after. Talk to us a little bit about
how that works, if you will. Sure. So as was alluded
to in the video, we really have a true
multidisciplinary program. And what I mean by true,
as opposed to virtual, is that we literally have our
dieticians and psychologists in the clinic with us. And we take turns seeing
the patients while they're in the clinic office.

And then we discuss and
confer amongst ourselves to really formulate
a good game plan. So this takes place
when patients come in for their initial evaluation. So we identify if there's
some particular behaviors or education that we can
work on to really get people ready to be
successful with surgery. And we also have the same
approach in the aftercare. And all of this
is really focused on selecting the
patients that we think will have the best
chance of success with surgery, and getting the best outcomes
that we can have after surgery. So really having
that team approach is I think what sets
us quite a bit apart. And it really sets the patients
up for success in the future. Absolutely. So we want to remind
our viewers that we are taking your
questions, so type them in the comments section. We'll try to get to
as many as possible. Let's start off talking
about the different types of bariatric surgery available. They were mentioned
in the video, but if you could tell us a
little bit about what they are, and what they entail. Sure. So there are currently four
approved bariatric surgeries that are performed nationwide.

We are one of the only
centers that actually offers all four types of surgeries. The most common one being
performed these days is something called
the sleeve gastrectomy, or vertical sleeve gastrectomy. Some people call it VSG. This is a procedure that's
done laparoscopically, which means surgery through
very small incisions. So most of the incisions are
about 1/4 of an inch or so.

And this can be done
with general anesthesia, and most people actually
wind up leaving the next day. So the sleeve gastrectomy
is a procedure which reduces the
size of your stomach by permanently removing
a portion of it. So I like to tell
people, if you think of your stomach
like a big handbag that you can stuff
lots of things into, if you were going
somewhere over the weekend. By removing a portion
of it, you basically are trimming it down to where
just the essentials fit in. So some people say
it's a banana shape, or I like to say
from the big handbag, to maybe just like a small
purse you would take to a party, or something like that. And so that reduces the
space where you can fit food, but also we've learned
that actually impacts some hormones in your
body that affect hunger and how full you feel. So it's not that you feel
hungry but can't eat, but it actually changes
the relationship that you have with food.

So that's why it's
one of the reasons that it actually works better
than restricting yourself on a diet. So that's currently the
most common procedure. Another procedure
that's performed, also laparoscopically, or
using the small incisions, is called the gastric bypass. Sometimes call it people
call it the Roux-en-Y. This is a procedure that's been
performed actually the longest for weight loss, since like the
'60s or something like that. And it has a really
excellent track record. Because it's been around,
there are some stories out there maybe that it was not
safe in the past, et cetera.

But this is actually
is not true. It's a very safe
procedure, likely as safe as all the other procedures. And it has certain
advantages over the sleeve. And sometimes we
recommended for people with severe heartburn or reflux. We may also recommend
it if you have diabetes on insulin,
such as the patient that was highlighted earlier. And it can be quite effective in
getting people off the insulin that they're on. The other procedure
is a procedure called the duodenal
switch, which is the procedure that
we specialize in here at the University of Chicago. Dr. Prachand was actually the
person to perform it first, using the minimally invasive
techniques here in the Midwest. And very few centers around
the country perform it. It is a little bit
more complex procedure, but also has more rewards. The duodenal switch
is a procedure that affords you the
most weight loss, particularly if you're in the
category of people who may need to lose around 200 pounds. And that's people whose BMI– which is body mass index– is over 50. And also, it's very
effective for people who have very severe
diabetes, that have been diabetic for greater
than 10 years on insulin.

And can be a very
powerful way to treat that metabolic disease,
that combination of obesity and diabetes. The last procedure
is something called the laparoscopic
adjustable gastric band. Technically we do
offer it, but it is a procedure that is
becoming sort of less popular these days, mainly
because it is a device. It is subject to
moving and breaking. And also we've seen
over the last few years that the weight loss is
not as effective as some of the other procedures. And so it is a procedure
that is approved, but we are actually performing
it less frequently, these days.

Now, we are getting
questions from viewers. I want to get to those,
and try to answer as many as we possibly
can during the program. First question,
which you pretty much just answered but we'll go
ahead and throw it at you again, anyway, when
you were talking about the duodenal switch. This is somebody
who says, do you think a person whose BMI is over
50 should think about surgery? And I guess, the question would
be, then, what types of surgery should they should
they first consider? And either one of you
can field that one. So you mentioned BMI
of greater than 50. So again, BMI stands
for body mass index. And we get that number by
combining height and weight into a formula, and it
gives a pretty good estimate of how much extra fat a
person has for their height. It's not a perfect
number, and you'll see a lot of news stories and
a lot of complaining about BMI. But the reality is
that, unless you're an NFL linebacker or a
professional athlete, it actually does a pretty
decent job of estimating this. So just to quickly
review, a normal BMI is between 20 and 25.

And a person is considered
obese if their BMI is greater than 30. And so we talk about
surgery for obesity when the BMI is 40 or higher,
or if it's between 35 and 40 and the person has other
significant medical problems related to their obesity,
as we mentioned earlier. So when we're talking about
BMI of greater than 50, that's typically somebody who's
150 to 200 pounds overweight. And typically, and frequently
associated with that are those other obesity-related
medical conditions like diabetes, high blood
pressure, and so forth. So in the past, when
gastric bypass was the most common
operation performed, say 15, 20 years ago, what
was seen quite frequently is that patients who had
BMIs greater than 50 or 60, they frequently failed to
lose enough weight after they had gastric bypass,
or they would regain a significant amount of weight.

And that's really what
prompted our interest in performing the
duodenal switch, because historically, it seemed
to be associated with a greater amount of weight loss. But there really had
not been any head to head studies comparing the
two operations to determine which is actually more
effective for this very difficult-to-treat group of
patients with a higher BMI. So we did the first study
comparing not only the weight loss, but the impact
on diabetes, high blood pressure, and high cholesterol. And we were the first
to find that there was, in fact, a significant
advantage for patients with greater than a BMI of 50.

Now, that doesn't mean
that every patient with the BMI of greater than 50
should have a duodenal switch. And I think that one of the
key things that we really try to convey to our
patients when they come for an evaluation,
and what we really take most of their time in our
conversations and discussions with patients, is figuring
out what the right tool is for you, as an individual. Because there's
not one operation that's the best for everyone
in all circumstances.

And so it's really about
finding the right match between the operation
and the patient, taking to account the
fact that each person has a different amount of weight
that they need to lose, each person has different
medical conditions that are related to their
obesity, different side effects of the operations,
and different effectiveness, in terms of weight
loss and impact on these medical conditions. And so that conversation
that we have as the surgeon with the patient
is really the key.

pexels photo 4676423

So we've talked about
people with the higher BMI. So we have a question
from a viewer, somebody without that level of BMI. And the question is, for someone
struggling to lose 25 pounds, would surgery be an option? Generally, probably not. Again, we don't necessarily
go by how much weight you're overweight, but the BMI. So you would have to
calculate your BMI. But the minimum BMI
is basically 40, which correlates to
roughly around 100 pounds for people who
are normal height. Or an average
height, I should say. Or if you're a BMI
is over 35 and you have a medical condition
closely related to obesity, such as diabetes, high blood
pressure, high cholesterol, or sleep apnea. Generally, if you're about
25 pounds overweight, you're probably
around a BMI of 30, again, if you're an
average height individual. And around that BMI, generally,
the first recommendation would be intensive
lifestyle modification, which is also the first
step for anyone who's trying to lose weight.

So that's, generally,
meaning working with a professional,
such as a dietician or a medical specialist that
works with obesity medicine. Or maybe even a therapist or a
psychologist that can help you lose weight. But having those regular visits
with professionals really been shown to affect
success with people trying to lose weight. And that's one of the nice
things about UChicago Medicine.

We do offer services
like that, as well, so we can cover the whole range. How safe is bariatric surgery? So I think that there is a
lot of myths and concerns, when it comes to surgical
safety with these operations. And again, this, I think,
dates back to 20 years ago, when these operations really
were considered to be risky. And frankly, there as a
lot of high-profile cases in the newspapers, and so forth,
as the operations initially started to become more popular. But over the years, with
modifications and techniques and the management
of these patients, using laparoscopic
approaches, instead of the traditional
open incision, which required a
pretty large incision extending from the breastbone
down to the belly button. By using these
approaches, and really the management of the
team, the safety today in centers of
excellence, such as ours, is very similar to patients
who have gallbladder surgery.

Which is to say that it's
a very safe operation. We have more questions
coming from our viewers. I've heard hair loss
can be a common side effect of bariatric surgery. Is there a way to
avoid this, and does it taper off on its own? This can happen after
bariatric surgery, but it can happen also
if you're losing weight with any other means. When you do lose a
significant amount of weight, particularly quickly, it is
the body's natural response to sort of make sure it's not
wasting resources, if you will. And not that hair is
a waste of a resource, but basically, it
does require protein from your body to make hair. So when you're in that initial
period of rapid weight loss, your body may say, let's
just see what's going on. Make sure we have
enough nutrients for essential functions. So it may shut down new hair
growth for a little bit, and that may come off as
seeing that you're losing hair.

Generally, this is temporary
and fully recoverable. And it generally is not
significant to a point where others would
notice, but you may notice that your hair is thinning. Our dieticians, who are
nutritional specialists that we work with, are very
good at counseling our patients through this period,
and making sure that they keep up with the
appropriate protein and vitamin recommendations that can really
limit the amount of hair loss that they experience, and
certainly help with the hair regrow period. We've got a follow-up
question to that. Let's talk a little bit about
the vitamins and supplements and things that people will
take after a surgery like this. How long does that go on,
and how significant is that? So with all of the operations
that we do, taking vitamins is something that's necessary
after surgery forever.

Each of the operations
is slightly different, in terms of the way that
the body absorbs and handles different nutrients and
vitamins, but in all cases, because of that
reduction in appetite and because there's less
food being taken in, if you don't get enough in and
if your body's not absorbing in the way that it
had been previously, you're at risk of
developing deficiencies. So taking vitamins every
day is an important part of being as successful as
you can be after surgery. I like to tell
patients, you wouldn't want to get a
transplant operation and then not take your
immune suppression medication afterwards. And you have to almost look
at vitamins in the same way, after you have these operations. One of the common
criticisms that people will make when they talk
about bariatric surgery is, oh, people will just
gain the weight back. Is that true? Or what do we do now
to try to prevent that? So if you look at, let's
say 100 people who've had bariatric surgery, the
majority of those patients– let's say 5, 10
years afterwards– will be down from the initial
point that they had surgery.

So let's say, if they
had 100 pounds to lose, the majority of them– that's
over 50% of those patients– will be down 60, 70, 80 pounds. It is very normal, though,
after the first year or two after the surgery, to regain
a little bit of weight. I tell my patients it's kind of
like setting your thermostat. You should think of
surgery as resetting your body's thermostat of where
the normal weight will be.

So initially, you will
lose a lot of weight, and your body will then
find its new steady state. And then everybody regains just
a little bit of weight back. And then it's our job
working with the patients to make sure that that
little bit of weight we gain, which is normal, stays at that
level, and doesn't you know skyrocket back so people are
getting excessive amounts of weight back. There are some patients that
do gain a significant amount of weight back, usually not to
the point where they start off at. But if you if they've
lost like 80 pounds, they may regain back
30, 40 pounds, which is not a result that we wanted. And we definitely work
with them to limit that. A major way to prevent
that from happening is close follow-up with
us, close follow-up with our dieticians, and
a continued understanding that surgery, as we
talked about earlier, is not the easy way out. It is basically a tool
to help you continue to do what you know you
should have been doing, which is modifying your
diet, increasing your physical activity,
and the everything else that we normally talk
about with weight loss.

So here's another question
right along those lines from a viewer. For those of us who have
had gastric sleeve surgery– this person was June
of 2014– they've gained some weight back. They want some motivation or
suggestions to kind of get back on track. What would you tell somebody to
jumpstart that process again, and how would you help? Sure. So the way that I would
begin with that patient is make sure that they go
in to see their surgeon, and re-engage with the program. Oftentimes, patients
will sort of drift away because of
job changes, or they move and so forth. And if they can come
back and see their team, that first step can
help substantially. Typically, what we would do
in that sort of circumstance is make sure that there's not
any sort of anatomic problem that might be contributing
to the weight re-gain. And at the same time, we
would have a full assessment by our dieticians
and our psychologists to make sure that the diet
hasn't drifted or shifted in a negative direction. And really kind of re-educating
and just getting back on track.

And to be honest, I
think that that's really where the value of the
long-term follow-up comes in. Because the reality is
that nobody can be perfect every single day,
multiple times a day for the rest of their lives. We kind of use a ratio of, if
you do the right thing 80%, 85% of the time, you're
going to be fine. And life happens. And there's things that happen
with regards to employment, relationships, and so
forth, and stresses that can lead to people
kind of getting off the track a little bit. And we're here for our
patients to really get them redirected and re-engaged
and moving forward again. Here's another viewer question. Not sure why this
one is being asked, but I'm going to go go ahead
and throw it out anyway. They want to know what form
of vitamins would they take.

Chewable, gummy, or pills? That's actually
a great question. After bariatric surgery,
we are, generally, altering the anatomy. So the way some things
are absorbed or taken up by your body is a
little different. And that's partially
how the surgeries work. So after certain
procedures, we do counsel our patients to take vitamins
that are absorbed better. Sometimes the gummy
vitamins, those are vitamins that can
basically dissolve in water. You chew them in
your saliva or spit, and they dissolve and
you can swallow them. And that's adequate for
some of the vitamins. But some vitamins
actually are not well absorbed in that
format, and we may then recommend different combinations
or formulations of vitamins that are better absorbed. Some vitamins, you
may notice, come in a little droplet of
oil, and those may not be good after
certain procedures. So we and our dieticians come
up with an individualized plan for each patient based
upon the surgery they had, and also, actually,
their pre-vitamin levels. You may have noticed in
Chicago that it's actually pretty cloudy today, so that
means vitamin D levels are low.

And actually, most people,
actually even before surgery, come in with some
low vitamin levels. And what we do is we actually,
before your surgery, check all those levels, come up
with an individualized plan about what your vitamin
regimen should be based on that and the surgery you've had. So each patient
will vary somewhat in what they'll have
to take, and how they'll have to take it. So here's an
interesting question. How do you make sure that people
don't lose too much weight? I don't know if that's ever
a concern with patients, but how would you handle that? Well, I think that it
is a realistic concern. I think patients all
have in their minds sort of what they would consider
to be a target or a goal weight, if you will.

And I would say
that the first step is you have the write
operation to begin with. As I said earlier,
there's not one operation that's best for everyone
in all circumstances. And it's really that initial
determination and decision that we come together with
the patient about the surgery a choice that will
significantly determine, not only the risk of
losing too much weight or also not losing
enough weight. So really finding that
sweet spot in between. So are there certain
foods or drinks that will be off limits
after the surgery? That's a great question. So again, it sort of depends
on the type of procedure you've had. In general, many people come
in thinking that, oh, gosh, I'm going to have to eat baby
food for the rest of my life, or just drink liquids.

That's actually not true at all. Our goal is to get you to eat
normal, healthy food again. And about three months after
the surgery, consistency-wise, there's really no restriction. So you can eat vegetables
again, you can eat meat again, all those things. But we do counsel
you on the types of foods you should be
avoiding, and foods that work against the weight loss. So a high-carbohydrate
diet, that's, again, a lot of starches,
flour rice, pasta, potatoes. Anything that has that sort
of white color and consistency is generally to be avoided,
mainly for weight loss. Sugars, sugary
things, sweet things. Again, works
against weight loss, but sometimes can make you
feel ill after certain types of surgery. So if you eat something that's
very sweet or high concentrated in sugar, that, again,
may not agree with you, and also is not good
for weight loss.

Generally, we tell people to
avoid carbonated beverages. That's things like
soda, beer, pop. Again, because as that
gas expands in the stomach that maybe a little smaller,
or in your intestine, that can be uncomfortable
and not make you feel well. So I would say
things to be avoided are carbonated beverages,
high sugars, and then high-carbohydrate foods. We're about out
of time, but I do want to ask this
one last question, and it's concerning insurance. Obviously, if you're going
to have a procedure done, there's always some concern
from the patient's standpoint on whether or not
something like this would be covered by insurance.

Can you speak to
that a little bit? Yeah. So I think that there's
a perception out there that these operations are
cosmetic, and in many cases, cosmetic operations are
not covered by insurance. But I think it's
really important to understand that these
obesity and metabolic operations are not cosmetic. As Dr. Hussain alluded
to, these things actually change the physiology
of the body and contribute to
the weight loss, as well as to the improvement in
the medical conditions related to obesity. And because of that
medical aspect, most insurance
companies actually do cover obesity surgery. Although the individual patient
has to look at their plan to see if it's a covered benefit. It turns out that, with the
reduction in medications and the overall gain and
health that takes place after these operations
in the long run, it's actually a cost
savings to the health care system for individuals to
undergo these operations. That makes perfect sense. Well, gentlemen,
thank you very much.

That was great. Thank you. Appreciate it. That's all the time we have
for At the Forefront Live. Thanks to our guests
for their participation in today's program,
and thanks to you for watching and
submitting questions. If you want more information
about bariatric surgery, please visit our website
site at uchicagomedicine.org, or you can call 888-824-0200. Join us for our next
At the Forefront Live, where we learn about
minimally invasive robotic cardiac surgery. That's Monday, February 4th. Also check out our
Facebook page for future At the Forefront Live
dates and subjects.

Thanks for watching,
and have a great week.

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