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How to Choose the Right Weight-Loss Surgery For You

When diet and exercise have not worked, there’s an alternative. John Yadegar, MD, Medical Director of the Bariatric Program at Palmdale Regional Medical Center, discusses how to choose the weight loss surgery that might be right for you.
How to Choose the Right Weight-Loss Surgery For You
Featured Speaker:
John Yadegar, MD
Dr. John Yadegar is the  Chief of Surgery and Medical Director of the Metabolic and Bariatric Surgery Center at Palmdale Regional Medical Center.

Learn more about John Yadegar, MD

Melanie Cole: When diet and exercise have not worked, there is an alternative, but with so many different kinds of bariatric surgery out there today, how do you choose the one that’s appropriate for you? My guest today is Dr. John Yadegar. He's the chief of surgery and medical director of the metabolic and bariatric surgery center and Palmdale Regional Medical Center. Who should consider bariatric surgery? What are the parameters for someone to even look at the different types of surgery available?

Dr. John Yadegar: Thank you very much for inviting me on this program. As you know, bariatric surgery has now been an established surgical approach for the last 20 years with a lot of literature and data that we have available for us. Over the years with these studies, we have been able to identify the ideal optimal procedure for the various groups of patients. We very much are following the National Institute of Health criteria and patients who meet the requirements for surgery should be what we call a body mass index of 35 or higher with a comorbidity. Body mass index is a ratio of your weight to your height squared and there are charts that patients can search and look up online. If you have a body mass index that is 35 or higher with a comorbidity, which could be a condition like diabetes or high blood pressure or high cholesterol, that patient will qualify for surgery. If, however, they have a body mass index of 40 or higher and do not have a comorbidity, that patient will also qualify for the surgical procedures. Being a patient who has trouble with obesity, of course, means that they do have potential risk factors and we want to make sure that we choose the right operation for the right patient. It's not one surgery fits all.

There are three approaches that are still utilized. One is the laparoscopic approach for gastric bypass, the other is the laparoscopic approach for sleeve gastrectomy, and for a selective group of patients, the laparoscopic gastric banding. There are some malabsorptive operations which we do still utilize, but that’s for highly selective groups of patients.

Melanie: Let's start with one of the more common ones that people have heard about, the gastric bypass. That one’s been around a very long time. Explain a little bit about what the bypass is and what somebody can expect from the procedure and life afterward.

Dr. Yadegar: The gastric bypass operation is a procedure where we divide a small portion of the stomach and that is now referred to as a pouch, that is completely separated from the main part of the stomach. This pouch is still connected to the esophagus which is the good pipe and in being downsized, the person is going to have a smaller capacity, they’ll have less hunger, but the food has to continue into the small intestine. The small bowel is brought up to this pouch and food bypasses the stomach and goes directly to the small intestine. There are certain lengths of the small bowel that are measured depending on the initial weight of the patient and the initial body mass index and that segment of the bowel is also bypassed. In essence, you're going to have a smaller capacity and a smaller absorptive capacity, and over the course of a year to 18 months, these patients tend to lose 80% to 85% of their excess body weight.

This particular operation is the one that has over the years really been studied extensively. It is perhaps the best match for a patient whose body mass index is greater than 50 and that's the group that is now referred to as super morbidly obese and also a patient who has what's referred to a metabolic syndrome. They do have diabetes, cholesterol, elevated blood pressure and possibly sleep apnea. That particular group is the group that would best do with a bypass because they're going to require to have a higher weight loss and to be able to resolve their diabetes and their metabolic syndrome. The studies have reflected that this would be the best match for the typical patient who may be 350 pounds or higher and suffers from these comorbidities. That certainly is a factor when we do visit with patients and risk stratifying them. Also, it's a very suitable operation for patients who may have challenges with starches and sugars because these patients, if they consume a higher quantity of these products, tend to have what's called a dumping syndrome after a bypass gastric, which is where this sugar load tends to make them have abdomen colic and spasms and they tend to feel nauseous and that’s a deterrent. They learn from this biofeedback to avoid that kind of behavior pattern, and as a result, they eat better and they lose optimal amount of weight and over the over the course of that 18 months, they'll get rid of their diabetes, their cholesterol, and their blood pressure and the results have been proven to be very effective.

Melanie: Now tell us about the sleeve gastrectomy because that’s also laparoscopic. People are starting to hear more and more about it and it’s becoming one of the more popular choices. Explain to us why.

Dr. Yadegar: The laparoscopic sleeve gastrectomy is a procedure where we downsize the stomach by removing 75% to 80% of the excess part. The remaining part is calibrated using a calibrating cube that allows standardization of what is left behind. By removing that excess part of the stomach, a lot of the cells that line that part of that removed stomach are the cells that produce a hunger hormone called ghrelin. By removing that mass, the ghrelin levels of the body drop, patients have reduced hunger and reduced capacity. The food however still goes through the stomach so it is somewhat physiologic. It doesn't have some of the malabsorptive challenges that a patient with gastric bypass may exhibit or develop and those are things like iron deficiency. From that standpoint, it seems to be a little bit more a balanced approach where it gives the patients a good weight loss, 70% to 75% of their excess weight, and at the same time doesn't give them some of those malabsorptive challenges, but still is going to help with their comorbid conditions such as blood pressure, diabetes and cholesterol. Historically, the gastric sleeve was an operation that was used as a stepping stone towards the gastric bypass. It was initially offered to patients that were super morbidly obese and were high risk to try and get their weight down initially and to offer them subsequently the second phase which would be a gastric bypass. In the follow-up of these patients, it was realized that they lost such a good amount of weight and got rid of a lot of their comorbidities that they were considering this as a single stage operation.

Over the 15 years that this procedure has been performed, it’s become apparent that it is a very good match for the lower body mass index patients with the lower comorbidities because the amount of weight loss that they’ll get from this operation often gets rid of their obese condition and gets rid of their comorbidities and has found its place in that group of patients with a body mass index of 35 to 50 perhaps with high blood pressure or with cholesterol or with diabetes and not necessarily all of them. They also have a group of patients who feels the bypass just is too aggressive for them. They conceptualize the sleeve as a more physiological operation and they seem to do better with it. Typically, as part of the workup towards these operations, patients are asked to change their behavior pattern, their lifestyle change to eat better, to exercise and to lose 5% or 10%. For those who are very successful in that, it’s a good indicator that the sleeve will be a good match. Your typical patient who weighs 280 pounds and has high blood pressure and goes through a preoperative workup and does 10 pounds of weight loss, that’s a good candidate for the sleeve because especially if they're younger, more active, they can lose a good amount and they can get rid of their metabolic condition and end up maintaining a good amount of weight loss. Typically, 15 to 20 years on, we know that with bypass and the sleeve, patients are able to sustain 60% to 65% weight loss, which is a remarkable number. Of course, it’s not 100%, but it’s the best we have. Study after study have consolidated this, so it’s a very good choice as is the bypass as long as you choose the right patient for that operation.

Melanie: To summarize, this is such good information and you’ve summarized it so well, please tell the listeners what questions that you would like them to ask to help decide which of these kinds, do the patients get to help decide? You’ve mentioned a bunch of parameters and there are so many other things involved, we could do so many shows about bariatric surgery, but what questions would you as a physician like listeners to be asking you when they come to see you for the first time?

Dr. Yadegar: The important decision the patient has to make is first to recognize the challenges that they have to recognize the condition because a lot of patients may not initially come to realize the significance of having a surgical intervention. First, I would like to make sure that the patient has thought it through, first, they recognize that they do have challenges with their weight and that they do have conditions that they have tried to resolve non-surgically. That means they have tried better eating patterns, eating protocols, they have done exercise routines and they have not been able to successfully sustain a weight loss. If they have reached that stage, then the next step for the patient is to recognize they're at a stage now where they feel they need to take a more aggressive approach and an intervention which would be surgery. I want them to be educated about the options that are available to them.  

The questions that are important to ask is ‘how this is going to impact my life and how is it going to improve my longevity?’ We don’t want them to just assume. We want them to know what evidence there is for these questions to be answered correctly and the evidence is overwhelming. We know that patients who have these operations do have improved longevity, they do have reduced risk of cardiovascular disease, they will have reduced risk of cancers, onsets or incidents of breast cancer, colon cancer, prostate cancer is reduced in patients who are no longer morbidly obese. It’s important for patients to recognize that it’s not just reducing their weight. It’s reducing their weight, which allows them to get rid of their morbid condition and allows them to have better health and better quality. It’s not always the disease processes that are improved. It’s their whole quality of life. It’s the fact that you can get on a plane and not have to worry about an extension for a seat belt. It’s the fact that you can go and hug the kids and they can hug you back. It’s the fact that you can bend over and tie a shoelace.

These are important things that patients tell a physician that you wouldn't often think about and that's the significance of this life-changing experience that you get healthier, you have a better quality and living longer for yourself and your family. We want to make sure that when they come through that they recognize the life-changing experience that they're going to step into. It's not easy. It's a lot of work, it's a lot of dedication and they need support and that's important.

Melanie: Thank you so much for explaining that so clearly so that we can understand the different types of surgery and which one might be appropriate for someone who is considering bariatric surgery. You're listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information, please visit Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if bariatric surgery might be right for you. This is Melanie Cole. Thanks so much for tuning in.