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Melanie Cole (Host): Being seriously overweight can lead to life threatening medical conditions such as severe diabetes, high blood pressure, sleep apnea, and more. When combined with a comprehensive treatment plan, bariatric surgery may often act as an effective tool to provide you with long-term weight loss and help you and help you increase your quality of health. My guest today is Dr. Harish Kakkilaya. He’s a surgeon with Bariatric Surgery Program at Our Lady of Lourdes Medical Center. Welcome to the show Dr. Kakkilaya. Tell us a little bit about bariatric surgery. Who should consider and look into bariatrics and are there certain parameters to consider?

Harish Kakkilaya, MD (Guest): Thanks for having me today on the show. As you know, obesity is a major crisis in the country and in the world. And 30-40% of people are obese and 6-7% of the population are morbidly obese. This 6-7% of population qualify for weight loss surgery. In fact, recently, we have been trying to reduce the criteria for weight loss surgery so that more and more people can get help from weight loss surgery and to help in not only losing weight, also to control diabetes, high blood pressure and other comorbid conditions associated with surgery. Right now, if you are obese, if your BMI is above 40, or if your BMI is 35 and you have comorbid conditions like diabetes, high blood pressure, sleep apnea, then you are a candidate for weight loss surgery. And if you are struggling with weight, and you have tried all kinds of diet and other programs and medications and have not been successful, you definitely have to talk to your doctor and consider weight loss surgery.

Melanie: So, there are some requirements in addition to that parameter, those parameters that you discussed Dr., so what about things like nutrition counseling, or psychological counseling before the surgery? Are all of those kinds of things also involved? What’s leading up to the surgery itself?

Dr. Kakkilaya: So, when you come and see us, we will evaluate you and we will look at your medical health. We will get a proper history and physical exam and then if you are a candidate for surgery, if you meet the criteria; then you will go through a nutritional educational program basically to prepare you for your weight loss surgery. Because there will be some special dietary requirements immediately after the surgery. Like if you had a sleeve gastrectomy, it will take you six weeks for you to go back to eating regular food because your stomach is stapled. When the stomach is stapled, it takes approximately six weeks for the stomach to heal. Until the stomach is completely healed, you should not be eating regular food. Because if you eat regular food, you can break the staples and you can have other complications from the surgery. So, you will be on a liquid diet for two weeks, then we progress your diet gradually as your stomach heals. After two weeks, you will be on a pureed diet, another two weeks, you will be on a soft diet. So, you have to go through a training program to learn all these different diets. It is not that complex. We train you very well. We also have a dietician who will work with you and we give you a booklet which gives all the instructions and immediately after the surgery when you go home, again, we give you all these instructions. It initially can look like a lot of work but as you come into the program, we make it very easy for you.

Melanie: So, speak about the types of bariatric surgery that you perform at Our Lady of Lourdes Medical Center, because people have heard about gastric bypass and now they are hearing about sleeve gastrectomy, but they don’t really understand what those are and really what the differences are.

Dr. Kakkilaya: Okay gastric bypass is the surgery that made weight loss surgery very popular, so
everybody has heard of gastric bypass. We started doing them in the late 90s. It became very popular as
people started losing weight and then we started doing them laparoscopically. That was a real
advantage when we started doing them laparoscopically. There was a real breakthrough in weight loss
surgery. That is when we reduced the complication rate and the results started becoming better. But
gastric bypass has a small percentage of complications. It is a little bit invasive and has some
complications, that is why we wanted to do a simpler operation.

Then we started doing gastric banding in the early 2000s. It became very popular and became the
number one operation by 2010, in the world in fact, but then we realized gastric band patients were not
doing as well as were the gastric bypass patients. And in fact, we hardly do any bands. The number of
gastric bands done in the country has dropped from 60% to 3% like in the last year, 2016, only 3% of all
procedures done were gastric bands. So, it is basically we are really not advocating anybody to have a
gastric band unless they cannot have the gastric sleeve or the gastric bypass. Then in late 2000, we
started gastric sleeve which was only possible because of advance in technology. Gastric sleeve is a big operation, but because we can do it laparoscopically, and with the advance in stapling technology, advance in laparoscopic surgery, we can do this surgery very safely.

So, there are a lot of advantages with the gastric sleeve operation because it is – in the gastric bypass, what we do is we create a small pouch by stapling across the top part of your stomach and rerouting a loop of bowel – a loop of small intestine, we bring it up to the pouch and connect it to the pouch. Okay, so what happens when you eat food, it only goes to this small amount of the stomach, a pouch which holds only around 50 ml of fluid and then it bypasses the entire stomach and goes into the small intestine. That is why it is called gastric bypass because it bypasses the majority of your stomach. So, with the gastric sleeve, it is a much simpler operation that what we do is we just make your stomach smaller. The normal capacity of our stomach is 1.5 liters. After the sleeve operation, it becomes 150 ml. so, we take around 70-80% of your stomach. We make the stomach smaller. So, that way it is a simpler operation and the results are equally good. The weight loss results I believe is as good as bypass with less complications. And some of the studies are showing that when you look at long-term results, I think the sleeve gastrectomy results are probably better than gastric bypass. Because we do see a lot of patients with gastric bypass over the years gain some of the weight back, which I haven’t seen much with the sleeve patients. I think sleeve patients can maintain their weight loss much longer term than with the bypass.

So, sleeve is an operation with less complications and it is as effective or more effective than the gastric bypass. So, that is becoming the number one operation world over. In the United States in 2016, around 60% of all surgeries done are gastric sleeve and then around 17% of procedures are bypass. So, gastric bypass is losing its popularity. It was around 25% two years ago, now it is only 17% and I think eventually we will see more and more people just doing gastric sleeve. I’m a big proponent of gastric sleeve operation because it is simple, it is effective, it has the least complications short term and long-term. Because you don’t get multiple episodes of malnutrition. You don’t get other long-term complications like iron deficiency anemia and other things you develop with the gastric bypass and you don’t need multiple other surgery to fix complications of the gastric bypass like with the gastric bypass you can develop like internal hernias and things like that. But that you don’t see with the sleeve operation. And the advantage of sleeve is after the sleeve is done is if there is a failure you can have another operation to fix it. But with the gastric bypass, if that was your first operation, you had that, and you did not lose weight, or if you failed that one, there is nothing else that really, we can do currently. There are not much options for further weight loss.

Melanie: And as we are discussing the differences between the two Dr. with bypass, it’s more of a
malabsorption type procedure, so what happens and even for sleeve, after the fact, do the patients
have to be on supplements for the rest of their life? What is life like afterwards as far as what they can
eat, going out, social life and that sort of thing.

Dr. Kakkilaya: That’s an excellent question. So, let me talk about first gastric sleeve and then the
gastric bypass. Gastric sleeve is mainly a restrictive and a hormonal operation, so it basically restricts
how much you can eat because you have a much smaller stomach. So, your – how much you eat, your portion size becomes really small, you will be eating three to four ounces a meal and we encourage you to have multiple meals in a day. You need to focus on how much protein you take around 60 to 80 grams of protein in one day, and also how much fluid you drink. These are the things you need to focus on.

With the gastric bypass, it is not only a restrictive operation where your portion size is small. Also, you will have some malabsorptive component because your stomach is bypassed and all the food that you eat does not get absorbed because the it bypasses part of the intestine as well. So, you can have some diarrhea, you can have some dumping and all that with the gastric bypass. So, with both operations you have to take multivitamins. But with the gastric bypass, you have to be very strict with your multivitamins because it is very common to develop vitamin B12 deficiency. It is common to develop iron deficiency with the gastric bypass, so you have to be on iron and multivitamins with that. With the gastric sleeve, you need to take multivitamins and calcium which are the only two things you have to take. With the gastric sleeve, we really don’t see much vitamin deficiency postoperatively like if somebody come back to me like after two years, three years, I hardly see any deficiency of vitamins, but with the gastric bypass, this is a lifelong thing. I have seen severe cases of iron deficiency anemia, B12 deficiencies with the gastric bypass operation which we don’t see much with the gastric sleeve. So, there is less maintenance with the gastric sleeve long-term than with the gastric bypass.

But we do recommend everybody should take multivitamins. To be honest, I think all of us should take. If you had weight loss surgery or you didn’t have weight loss surgery; I think everyone should be on multivitamins and other supplements because our diet right now is not very nutritious. What we get in supermarkets have lost most of their nutritional value and we see a lot of vitamin deficiency in people who haven’t had weight loss surgery. So, it is a good point for all of us to take a multivitamin.

Melanie: And what about resuming activity, getting back into exercises and as we said in the intro Dr., it is really a tool to weight loss. It is not the absolute answer. So as a tool, what else would you like to in summary, let the listeners know, that they can expect from a surgery such as this and what they are also going to have to really think about for the rest of their lives as far as activity and all of those kinds of things. Please wrap it up for us.

Dr. Kakkilaya: Absolutely. Physical activity is the most important aspect to this. Surgery is just a tool. So, you will have the surgery. The surgery will help you to lose weight because it will reduce the portions of food that you eat. Now it is up to you what kind of choices we make. You have to change your lifestyle. You have to change what we eat and how much we eat. The reason - the causes for obesity are multiple. One is the food that we eat and how much we eat so we have to address that if we are to have long-term success. Lack of sleep is another cause of obesity, so we have to make sure that we get a good night’s sleep. Physical activity is one of the most important things and stress. We have to try our best to reduce the stress and increase our physical activity. Now after any of these operations done laparoscopically, you will be walking on the day of surgery. And then we go home, you should be walking. So, from day one after the surgery we encourage you to walk. Then after six weeks from surgery, we encourage everybody to go to the gym and do all kinds of physical activities, cardio exercises to encourage losing weight. So, physical activity is very important. Walking is good enough in the initial phase. Walking is one of the good ways of losing weight exercising. Then of course everybody has to follow their diet to have a long-term good outcome with this operation.

Melanie: It is such great information and so important for listeners to hear. Thank you so much Dr. for being with us today. This is Lourdes Health Talk and for more information on bariatric surgery at Our Lady of Lourdes Medical Center you can visit www.lourdesnet.org, that’s www.lourdesnet.org. This is Melanie Cole. Thanks so much for listening.