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Dr. Michael Smith (Host):  Bariatric surgery refers to a series of weightloss procedures that an obese individual can have in order to reduce their food intake therefore causing them to lose weight. Welcome to The GW HealthCast. I’m Dr. Mike Smith and todays topic: The Latest Techniques in Weightloss Surgery. My guest is Paul Marino. Paul is a Physician Assistant with over 30 years of experience in all aspects of surgical patient care with a concentration in general surgery and bariatric weightloss surgery and is affiliated with The George Washington University Hospital. Paul, welcome to the show.

Paul Marino, PA-C (Guest):  Thank you. Thank you very much.

Host:  I know many people are very interested in weightloss surgery. We know that being overweight and the obesity rates continue to climb in this country, so, I have a lot of listeners that are going to be very interested in this topic. But before we dive deep into those latest techniques; I thought maybe you being somebody with 30 years’ experience, could give us a little bit of a background first, about weightloss surgery. Like where were we and where are we today when it comes to bariatric surgery?

Paul:  Well bariatric surgery actually has a very long history. As you said, I’ve been doing this for over 30 years and when I was doing my surgical training, part of it was helping someone do weightloss surgery which was basically back then, just an intestinal bypass. Since that time, weightloss surgery has really advanced and there are a number of procedures. The most common was what was called a Roux-en-Y gastric bypass where a small pouch was made out of the stomach and then a portion of the small intestine was bypassed. And this was very effective, and it was considered the gold standard of weightloss surgery up until about ten years ago.

A little longer than that ago, the adjustable gastric band came on the scene. And most people are familiar with the term lap band which is a small band that is placed around the top of the stomach and causes you to have a small pouch at the top of the stomach where food comes in, fills the pouch, it sends a signal to your brain that you are full and then after liquification goes and the food passes, that will take several hours and then you are hungry again. That was a much safer operation because there was no rerouting of the GI tract at all. But it also wasn’t as effective.

The gastric bypass gave about – if you took all comers, it gave about a 65% excess body weightloss which means if you are 100 pounds overweight, you lost about 65 pounds. The lap band itself, gave you about a 40 – 45% excess body weightloss. So, if you are 100 pounds overweight, you lost 40-45 pounds.

Since that time, and with the history of people just getting larger and larger, there are those people who are in the super morbid obese range which means over 500 or 600 pounds. One of the pioneers in treating those patients, developed the sleeve gastrectomy as a first stage operation for someone in that weight range who was too sick to undergo major GI surgery and used this as a way to lose weight initially to get them so they are healthy enough to undergo a larger surgery. And it turned out that people were effectively losing weight over time, so, it then became an investigational procedure and then about eight or nine years ago, it became a mainstream procedure and now it is very standardized and used worldwide and it is now the most popular weightloss surgery in the world, actually. Not just in this country.

Host:  Wow, yeah. We are definitely going to get into that a little bit, but before we do though, just in case we have some people listening in the audience here who maybe are interested, maybe they have been thinking about weightloss surgery as something that they need to start considering. What are some of the parameters? What are some of the guidelines that you can lay out for us for people who should seek this out?

Paul:  Okay. So, in order to qualify for bariatric surgery, in most instances, and this is for coverage by insurance or Medicare; the guidelines were actually established in 1994, when bypass surgery was done open and not laparoscopic and had much higher risk factors associated with it than it does now. But those parameters still exist and that is you have to have a body mass index of 40 or a body mass index of 35 with a comorbid illness and that would be something like hypertension, high blood pressure, sleep apnea, hyperlipidemia, or diabetes. And if you had a BMI of over 40, you didn’t need any comorbid illnesses. But those would be the qualifications you would need to have in order to be accepted by most insurance companies to qualify.

And that usually comes out to around 100 pounds overweight, if you were going to go in general just by weight itself.

Host:  100 pounds, so that’s kind of a good guideline for some of the listeners, 100 pounds overweight, you probably need to go ahead and talk to your doctor. And again though, I also want to set the expectation for people who are listening who might fall into that category. It isn’t just about the surgery, right? Tell us a little bit about what goes on preop and postop to make sure that the outcome is exactly what we want.

Paul:  Okay. Preoperatively, the patient has to do a little bit of work. I mean all of this, it does entail work. The operation itself helps make the nearly impossible possible. And by that, I mean, without surgery, if you body mass index is over 40; you have about a five percent chance of losing 10% of your excess body weight. And then you have a five percent chance of keeping it off for two years.

So, in order to prepare yourself for bariatric surgery, we do – most patients will have to undergo some sort of monitored weightloss program for at least one visit with a - comprehensive visit with a dietician and physician and in most cases at least three monthly consecutive visits and in some cases, on up to six months depending on the insurance. But those are things you have to go through and that helps determine that you can follow a program and you have the discipline in order to continue after you have your surgery.

Also, you’ll have to have a psychological evaluation to make sure once again, that you can stick with a program and you have the right mindset to go forward. You will need a battery of also medical tests. We require at least an upper GI where patient drinks some barium and we get pictures of the esophagus and the stomach and the upper GI tract to make sure everything is the way it should be and there are no anomalies. And depending on the findings of that, we may send the patient for an endoscopy where the gastroenterologist actually puts a scope down into the esophagus and stomach to make sure things are as they should be.

Because we want an ideal situation before we start. All the patients will be tested for sleep apnea unless we already know that they have obstructive sleep apnea and they have CPAP or BIPAP to help them breath at night.

So, those are pretty much the things you have to go through to make sure – oh and one other thing. Before surgery, just before surgery, for a couple of – for two weeks before surgery; the patients also have to go on a very low carbohydrate diet to help shrink the liver, because we are working all up in the very high up in the abdomen and the liver comes right across and we need to be able to move the liver out of the way in order to be able to complete this surgery. So, we have them on a very low carbohydrate diet for two weeks prior, to help shrink the liver.

Host:  Yeah, that’s very interesting. But I’m glad you went over all that Paul because I think everything you said is very important. At the end of the day, the message is, it’s not just the surgery, right? There are – there is a test to make sure that you are committed to this, that there is effort that you have to put into this. The surgery can work, but it takes effort from the patient and the patient’s loved ones and the family to really make this work. So, I’m glad you went over all of that Paul. Let’s bring this now to the more technical part of our conversation. Tell us now specifically about the sleeve gastrectomy.

Paul:  The sleeve gastrectomy is actually is a very simple and straightforward procedure. The stomach is shaped sort of like an L with the outer portion being very large. So, that’s considered the greater curvature of the stomach. What we do in the sleeve gastrectomy, is we put a calibration device during surgery, anesthesia will put a calibration device down the person’s esophagus, into the stomach. So, we know exactly the size of the sleeve that we are going to make. And then, we actually take a stapler and go from almost the bottom of the stomach all the way up to where the stomach joins the esophagus, along that calibration device and we staple off the stomach and just make it into a smaller – a small tube. And we actually remove the portion of the stomach that we stapled off.

We actually remove the greater curvature of the stomach and take it out of the abdomen. And that’s a very important part of the operation. Making the sleeve or that small tube is good in that decreases the amount of food you eat at any one time. But removing the greater curvature; part of that is the fundus of the stomach which is the upper part of the greater curvature and that is where a hunger hormone is made. A hunger hormone called ghrelin. And that’s responsible for our hunger throughout the day. It’s been described as the hormone that causes you to put food in your mouth. And about 90% of that is made in the fundus of the stomach and when we remove the fundus of the stomach; then there’s only a very small amount left, and this has been measured on out to about ten years now. Once the level drops, it stays low. So, it’s not like you go and start making more ghrelin somewhere else.

And that’s a very important part because it really helps people. If you’re not hungry, you are not looking for food. And that really helps people stay focused and keep their weight off.

Host:  And so, is the sleeve gastrectomy something that most patients who are undergoing bariatric surgery will undergo? Is this – how common is this procedure?

Paul:  This is the most common bariatric procedure currently used worldwide. Because it has a very high safety profile and it has a very good weightloss profile. As I mentioned earlier, the gastric bypass used to be considered the gold standard. And that will give you about a 65% excess body weight loss if you take all comers. The sleeve gastrectomy will give you the exact same excess body weightloss figures and it also will, as will the bypass, by the way, help mitigate early type 2 diabetes because there are hormonal effects from both of these operations. So, they help not just with weightloss, but they help mitigate type 2 diabetes, hypertension. People who have hypertension they – with even modest weightloss; we have remarkable decreases and people coming off all types of medications.

Host:  Nice. Very impressive. This has been a great conversation Paul. A lot of really good information. Let’s end with this, what would you like people to know about bariatric surgery?

Paul:  It’s very important for people to know that bariatric surgery is not an easy way out. It’s not a coward’s way out. It’s not used for people who don’t have willpower. It is proven statistically that it is almost impossible to lose weight once your BMI is over 40 or even over 35. And so, this is a necessary tool. It helps people achieve the nearly impossible. It helps them achieve weightloss. And more importantly, it helps them maintain weightloss throughout the rest of their life so that they can have a relief from type 2 diabetes, they can have relief from hypertension or at least diminish the progression of those diseases. So, it is a very important tool for those people who are overweight and have struggled for years with trying to lose weight and could not and cannot maintain it.

Most patients, when they come to us, they have lost the same 20, 40, or 50 pounds over and over and over. With weightloss surgery, you only have to do it one more time and then you have much more likelihood of keeping it off.

Host:  That’s great. Paul, I want to thank you for the work that you’re doing and thank you for coming on the show today You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Marino or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment.