Selected Podcast
Clarifying Misconceptions about Bariatric Surgery
Dr. Cepeda addresses and clarifies different misconceptions about bariatric surgery.
Featuring:
Jaime Cepeda, MD
Dr. Jaime Cepeda Jr. is a board-certified surgeon specializing in General, Bariatric and Vascular surgery procedures. He is a Fellow of the American College of Surgeons (FACS) and a member of the American Society for Metabolic and Bariatric Surgery (ASMBS). Dr. Cepeda has over 15 years in general and laparoscopic surgery. He has been performing Bariatric surgery since 2008 performing hundreds of bariatric surgeries, including Laparoscopic Gastric Bypass, Laparoscopic Sleeve Gastrectomy, and Laparoscopic LapBand. Transcription:
Melanie Cole: Welcome to Doc talk presented by Montefiore St. Luke's Cornwall. I'm Melanie Cole and today we're clarifying misconceptions about bariatric surgery. Joining me is Dr. Jaime Cepeda. He's a Bariatric Surgery Specialist at Montefiore St. Luke's Cornwall. Dr. Cepeda, let's just start with one of the bigger misconceptions. Is bariatric surgery dangerous?
Dr. Cepeda: I think you're correct on that, Melanie. That is one of the biggest misconceptions when we think about bariatric surgery. To be quite honest with you, the perception of bariatric surgery has really changed and done a 360 within the last, say five to 10 years. And that's really with the advent of the technology and the ability to do most of these procedures, minimally invasive and laparoscopic. Many patients are very familiar with appendectomies or gallbladder removals. And when we look at the 30 day mortality rate of bariatric surgery, that rate is about 0.13%. In comparison to those two other operations appendectomies the rate is about 0.7, 4%. And something as simple as a gallbladder is about anywhere from 0.2 to 0.6%. So bariatric surgery in today's time is very safe.
Host: Well, thank you for clarifying that answer. Another big one, I'm an exercise physiologist Doctor and one that I hear a lot is that people think bariatric surgery is a cop-out that willpower plus good diet and exercise work just as well. What do you say about that?
Dr. Cepeda: Yeah. Bariatric surgery is by no means a cop out. It is not an easy way out, nor is it a quick fix and that deals with multiple perspectives. The biggest step is for those patients to kind of commit and actually get it in their mindset that this is an overall lifestyle change. The operation is not a cure all and simply a tool to help them get to their goal. But there's a lot of things that go into it. As a exercise physiologist, you know that as patients lose weight, they also lose muscle mass and therefore their energy expenditure is less than they have to do more to lose weight and do more to keep that weight off. So with regard to that, with regard to the overall lifestyle change and everything that needs to be done in order to be successful, bariatric surgery is not a quick fix or an easy way out. These patients have to be truly dedicated and determined to become healthier and live a healthy lifestyle.
Host: As someone who's seen many people go through it, I couldn't agree with you more. It is a tool as you said, to help them, but it is not an easy out. It is difficult. It requires lifestyle changes. It's not easy by any means. Does it matter what type of surgery? Because we hear about gastric sleeve, we hear about bypass, people have heard about lap band, which is really not being done as much anymore. You know, tell us a little bit about, does it matter about the type that you have?
Dr. Cepeda: It does, and it really is a thin that depends on the patient number one, and what they're comfortable with it also depends on their comorbidities and what they're striving for. Just a quick comparison of the three operations. When we look at the three bariatric procedures that we perform at St. Luke's, across the board with being banned, sleeves, and bypasses. If we look first at just overall weight loss or success, patients that opt for the lap band can look to lose about 25 to 35% of their excess body weight. We start looking at our staples procedures, meaning the sleeve or the bypass, whereas the sleeve, our patients will lose about 60 to 65% of their excess body weight. And our bypass is about 65 to 70% of their excess body weight. One of the big determining factors on whether or not a patient will choose a sleeve or a bypass has to do with their comorbidities.
And that's where we, you know, give them some helpful hints as to what they can expect. Patients who have poorly controlled diabetes typically do better with the gastric bypass. For the reason that gastric bypass has a higher cure rate for diabetes, an excess of about 90 to 94% as opposed to the sleeve where those cure rates for diabetes are a little lower, probably in the mid eighties. So if I have a patient that has a poorly controlled diabetic and is open to the idea of bypass, I think that would be a better operation for them. The flip side of that are patients who are smokers have a higher risk with bypass. So therefore those patients who are attempting to quit, which can be very difficult for some of these patients. I rather them have a sleeve which is a lot safer operation for a patient who may run the risk of returning to tobacco use. So every patient kind of has a niche in which operation would work better for them.
Host: And it is very individual. So another question that I hear quite often is the chance, you already mentioned that this is a safe surgical procedure, but is it safer than the chance of dying from obesity and obesity related comorbid conditions? Because that seems to be the confusion. Do I go through with surgery or is obesity itself going to contribute to, as you said, diabetes and heart disease and high blood pressure? Tell us about the comparison and why it's so important that people that are morbidly obese consider these procedures.
Dr. Cepeda: Absolutely. That's a great question. And there's a lot of data out there that can put this myth to bed. When we look at the reduction in mortality for obese patients, there is an 89% reduction in mortality for a patient who undergo surgery versus an obese patient who does not undergo surgery. And that has been proven through various studies with regard to cancers, diabetes hypertension and strokes. By having this procedure, they decrease their mortality rate considerably.
Host: So then tell us about the surgery itself. Is it considered cosmetic? Is it covered by insurance? And people also wonder if they're going to need plastic surgery for excess skin afterwards? Can you clear up those two for us?
Dr. Cepeda: Absolutely. Bariatric surgery is not cosmetic. It is a procedure that is covered by a majority of the insurance carriers. There are some qualifications. Patients must have a BMI in excess of 35, BMI of 35 to 40. Those patients must have a comorbidity. Those comorbidities could be anything from diabetes, sleep apnea, hypertension, joint disease, patients who have a BMI of greater than 40, that becomes a comorbidity in itself. So if you have a patient that has a BMI of 44 or 45 and they are a quote unquote healthy obese patient without the comorbidities, they still qualify for bariatric surgery. With regard to needing plastic surgery after weight loss surgery. It is a question that comes up very, very often. But when we look at our patient population and some of the literature, only about 50% of patients ever move forward and have some type of skin reduction or skin removal surgery. That's something that our practice does offer as well. There are some guidelines and most times those procedures are covered by insurance companies as well and not seen as cosmetic.
Host: This is really great. You are answering so many questions, Dr. Cepeda, and really clearing this up. Can somebody be too heavy for bariatric surgery, and if they have comorbid conditions, do they still need to take insulin or blood pressure medication after this surgery?
Dr. Cepeda: Let me answer your first question. With being too heavy for bariatric surgery, there are some weight restrictions and that typically deals with the facility. We don't want to have a patient who is an excess of let's say 600 pounds, have an operation and the facility not be able to have equipment to take care of that patient. A lot of those weight restrictions hover around the weight of five to 600 pounds. We have done some patients that are slightly over 500 pounds, but as we meet them and they become involved in the program during those first three to six months, which sometimes it can take, we try to get them below that level of 500 so that we have a facility that has equipment that can take care of them. The second question with regard to patients continuing to need their medications, we see a majority of our diabetic patients that are on either oral hypoglycemic or medications or some insulin after the day of surgery, never return to those medications. Patients who are on high dose insulin therapies will see a significant decrease in the amount of insulin that they need or they may switch from insulin only to maybe an oral agent instead, within the first year. With regard to hypertension, those medications and hypertension tends to take a little longer to start to resolve. So they'll continue on those medications and be reassessed and reevaluated by their cardiologist to see when either of those medications can be reduced or those patients can be taken off those medications.
Host: Well, thank you for joining us. And before we wrap up, give best advice, tell us a little bit about your outcomes, what you've seen for bariatric patients, about the way that this can be life changing, but that it is a tool. It is not easy, but that it is very safe. Wrap it up for us, Doctor.
Dr. Cepeda: Well, they are trick surgery is something that you, that all patients must really consider and think of the entire scope of what it entails. And in order to be successful, you need to be, and I program that kind of deals with all patients in a multidisciplinary approach. As we said early on, the surgery itself was one part of it. And just a tool, but it's the aftercare, it's the follow-up. It's the dieticians and nutritionists, the nurse practitioners, the behavioral health, everything that wraps it up together so that that patient can be successful and lead a healthy life. And I'll tell you, every patient that has been successful in our program comes back and tells us how important our program was to them and how it's changed your life and not only their life but their family's lives. They're able to go out and play with their children or play with their grandchildren and not be left behind and actually interact with those family members. And not only that, but change their lives of their children because of what they've done in changing their eating habits and their overall lifestyle as well.
Host: It's great information, you so much Doctor, for coming on and really clearing up some of those main misconceptions. You've given us a very clear picture of what this entails and how important it is for people that are morbidly obese to really consider this procedure. To contact the bariatric surgery team at Montefiore St. Luke's Cornwall, please call (845) 568-2825 or you can visit Montefioreslc.org for more information and to get connected with one of our providers. That concludes this episode of Doc Talk presented by Montefiore St. Luke's Cornwall. Please remember to subscribe, rate, and review this podcast and all the other Montefiore St. Luke's Cornwall podcasts. I'm Melanie Cole.
Melanie Cole: Welcome to Doc talk presented by Montefiore St. Luke's Cornwall. I'm Melanie Cole and today we're clarifying misconceptions about bariatric surgery. Joining me is Dr. Jaime Cepeda. He's a Bariatric Surgery Specialist at Montefiore St. Luke's Cornwall. Dr. Cepeda, let's just start with one of the bigger misconceptions. Is bariatric surgery dangerous?
Dr. Cepeda: I think you're correct on that, Melanie. That is one of the biggest misconceptions when we think about bariatric surgery. To be quite honest with you, the perception of bariatric surgery has really changed and done a 360 within the last, say five to 10 years. And that's really with the advent of the technology and the ability to do most of these procedures, minimally invasive and laparoscopic. Many patients are very familiar with appendectomies or gallbladder removals. And when we look at the 30 day mortality rate of bariatric surgery, that rate is about 0.13%. In comparison to those two other operations appendectomies the rate is about 0.7, 4%. And something as simple as a gallbladder is about anywhere from 0.2 to 0.6%. So bariatric surgery in today's time is very safe.
Host: Well, thank you for clarifying that answer. Another big one, I'm an exercise physiologist Doctor and one that I hear a lot is that people think bariatric surgery is a cop-out that willpower plus good diet and exercise work just as well. What do you say about that?
Dr. Cepeda: Yeah. Bariatric surgery is by no means a cop out. It is not an easy way out, nor is it a quick fix and that deals with multiple perspectives. The biggest step is for those patients to kind of commit and actually get it in their mindset that this is an overall lifestyle change. The operation is not a cure all and simply a tool to help them get to their goal. But there's a lot of things that go into it. As a exercise physiologist, you know that as patients lose weight, they also lose muscle mass and therefore their energy expenditure is less than they have to do more to lose weight and do more to keep that weight off. So with regard to that, with regard to the overall lifestyle change and everything that needs to be done in order to be successful, bariatric surgery is not a quick fix or an easy way out. These patients have to be truly dedicated and determined to become healthier and live a healthy lifestyle.
Host: As someone who's seen many people go through it, I couldn't agree with you more. It is a tool as you said, to help them, but it is not an easy out. It is difficult. It requires lifestyle changes. It's not easy by any means. Does it matter what type of surgery? Because we hear about gastric sleeve, we hear about bypass, people have heard about lap band, which is really not being done as much anymore. You know, tell us a little bit about, does it matter about the type that you have?
Dr. Cepeda: It does, and it really is a thin that depends on the patient number one, and what they're comfortable with it also depends on their comorbidities and what they're striving for. Just a quick comparison of the three operations. When we look at the three bariatric procedures that we perform at St. Luke's, across the board with being banned, sleeves, and bypasses. If we look first at just overall weight loss or success, patients that opt for the lap band can look to lose about 25 to 35% of their excess body weight. We start looking at our staples procedures, meaning the sleeve or the bypass, whereas the sleeve, our patients will lose about 60 to 65% of their excess body weight. And our bypass is about 65 to 70% of their excess body weight. One of the big determining factors on whether or not a patient will choose a sleeve or a bypass has to do with their comorbidities.
And that's where we, you know, give them some helpful hints as to what they can expect. Patients who have poorly controlled diabetes typically do better with the gastric bypass. For the reason that gastric bypass has a higher cure rate for diabetes, an excess of about 90 to 94% as opposed to the sleeve where those cure rates for diabetes are a little lower, probably in the mid eighties. So if I have a patient that has a poorly controlled diabetic and is open to the idea of bypass, I think that would be a better operation for them. The flip side of that are patients who are smokers have a higher risk with bypass. So therefore those patients who are attempting to quit, which can be very difficult for some of these patients. I rather them have a sleeve which is a lot safer operation for a patient who may run the risk of returning to tobacco use. So every patient kind of has a niche in which operation would work better for them.
Host: And it is very individual. So another question that I hear quite often is the chance, you already mentioned that this is a safe surgical procedure, but is it safer than the chance of dying from obesity and obesity related comorbid conditions? Because that seems to be the confusion. Do I go through with surgery or is obesity itself going to contribute to, as you said, diabetes and heart disease and high blood pressure? Tell us about the comparison and why it's so important that people that are morbidly obese consider these procedures.
Dr. Cepeda: Absolutely. That's a great question. And there's a lot of data out there that can put this myth to bed. When we look at the reduction in mortality for obese patients, there is an 89% reduction in mortality for a patient who undergo surgery versus an obese patient who does not undergo surgery. And that has been proven through various studies with regard to cancers, diabetes hypertension and strokes. By having this procedure, they decrease their mortality rate considerably.
Host: So then tell us about the surgery itself. Is it considered cosmetic? Is it covered by insurance? And people also wonder if they're going to need plastic surgery for excess skin afterwards? Can you clear up those two for us?
Dr. Cepeda: Absolutely. Bariatric surgery is not cosmetic. It is a procedure that is covered by a majority of the insurance carriers. There are some qualifications. Patients must have a BMI in excess of 35, BMI of 35 to 40. Those patients must have a comorbidity. Those comorbidities could be anything from diabetes, sleep apnea, hypertension, joint disease, patients who have a BMI of greater than 40, that becomes a comorbidity in itself. So if you have a patient that has a BMI of 44 or 45 and they are a quote unquote healthy obese patient without the comorbidities, they still qualify for bariatric surgery. With regard to needing plastic surgery after weight loss surgery. It is a question that comes up very, very often. But when we look at our patient population and some of the literature, only about 50% of patients ever move forward and have some type of skin reduction or skin removal surgery. That's something that our practice does offer as well. There are some guidelines and most times those procedures are covered by insurance companies as well and not seen as cosmetic.
Host: This is really great. You are answering so many questions, Dr. Cepeda, and really clearing this up. Can somebody be too heavy for bariatric surgery, and if they have comorbid conditions, do they still need to take insulin or blood pressure medication after this surgery?
Dr. Cepeda: Let me answer your first question. With being too heavy for bariatric surgery, there are some weight restrictions and that typically deals with the facility. We don't want to have a patient who is an excess of let's say 600 pounds, have an operation and the facility not be able to have equipment to take care of that patient. A lot of those weight restrictions hover around the weight of five to 600 pounds. We have done some patients that are slightly over 500 pounds, but as we meet them and they become involved in the program during those first three to six months, which sometimes it can take, we try to get them below that level of 500 so that we have a facility that has equipment that can take care of them. The second question with regard to patients continuing to need their medications, we see a majority of our diabetic patients that are on either oral hypoglycemic or medications or some insulin after the day of surgery, never return to those medications. Patients who are on high dose insulin therapies will see a significant decrease in the amount of insulin that they need or they may switch from insulin only to maybe an oral agent instead, within the first year. With regard to hypertension, those medications and hypertension tends to take a little longer to start to resolve. So they'll continue on those medications and be reassessed and reevaluated by their cardiologist to see when either of those medications can be reduced or those patients can be taken off those medications.
Host: Well, thank you for joining us. And before we wrap up, give best advice, tell us a little bit about your outcomes, what you've seen for bariatric patients, about the way that this can be life changing, but that it is a tool. It is not easy, but that it is very safe. Wrap it up for us, Doctor.
Dr. Cepeda: Well, they are trick surgery is something that you, that all patients must really consider and think of the entire scope of what it entails. And in order to be successful, you need to be, and I program that kind of deals with all patients in a multidisciplinary approach. As we said early on, the surgery itself was one part of it. And just a tool, but it's the aftercare, it's the follow-up. It's the dieticians and nutritionists, the nurse practitioners, the behavioral health, everything that wraps it up together so that that patient can be successful and lead a healthy life. And I'll tell you, every patient that has been successful in our program comes back and tells us how important our program was to them and how it's changed your life and not only their life but their family's lives. They're able to go out and play with their children or play with their grandchildren and not be left behind and actually interact with those family members. And not only that, but change their lives of their children because of what they've done in changing their eating habits and their overall lifestyle as well.
Host: It's great information, you so much Doctor, for coming on and really clearing up some of those main misconceptions. You've given us a very clear picture of what this entails and how important it is for people that are morbidly obese to really consider this procedure. To contact the bariatric surgery team at Montefiore St. Luke's Cornwall, please call (845) 568-2825 or you can visit Montefioreslc.org for more information and to get connected with one of our providers. That concludes this episode of Doc Talk presented by Montefiore St. Luke's Cornwall. Please remember to subscribe, rate, and review this podcast and all the other Montefiore St. Luke's Cornwall podcasts. I'm Melanie Cole.