Bariatric Surgery: Discovering the Right Option for You

Bariatric Surgery: Discovering the Right Option for You


>>BRADLEY NEEDLEMAN, MD: My name is Brad Needleman.
I’m one of the surgeons and Medical Director of The Ohio State University Medical Center
Bariatric Surgery Program. I’ve been the medical director for the last
ten years, and what I hope to do in this presentation is give you some more information about bariatric
surgery and help you decide whether or not this option is right for you. When we think about bariatric surgery, we
think about people who have come to a point in their lives where their weight’s become
a problem for their life and their health. We know that by being overweight there are
many medical problems like diabetes, high blood pressure, sleep apnea. And we’ll talk
about many of those things in this presentation. But I think many people come to this point
because they want to see that light at the end of the tunnel, that these things can get
better, that they can lose the weight, and bariatric surgery is often an essential step
in getting them there. When choosing a place for bariatric surgery,
we think it’s very important to choose the right place for you. You have to be comfortable with the hospital
facilities as well as the people that are going to be taking care of you. One of the things that are nice about Ohio
State University is some of this homework has been done for you. Our program is a Center of Excellence program
based on the American Society for Metabolic and Bariatric Surgery criteria. We’ve been a Center of Excellence since 2005
and were renewed in 2009 through 2013. As a tertiary care center, we also have pretty
much every specialist you’d be wanting to help with your care. Fortunately, most patients
don’t need these specialists, but there would be no reason for you to ever to seek care
outside the medical center. As a surgeon, I always joke that I’m really,
really important for one day of your care, your operation. And in reality, what you really need to be
successful with weight loss surgery is a good team taking care of you. The operation is
just one step in this whole process towards weight loss and healthier living. Not only is the operation important, but preparing
you for surgery is important as well. At Ohio State, we’re fortunate to have dedicated nurses,
nurse practitioners, dietitians and psychologists that can help make sure we help choose the
right operation for you, that we help you have a safe operation and help you have the
best possible outcome from your operation as well. We all know that in addition to having a good
operation, making necessary changes in lifestyle regarding diet and physical fitness is very
important to your overall success. The next step in deciding if bariatric surgery
is right for you is to see if you’re a candidate. One of the methods we use to determine candidacy
for weight loss surgery is BMI, or body mass index. There’s a chart that can help you decide this,
but essentially we look at your height versus weight ratio. So if your weight in kilograms divided by
your height in meters squared. If your BMI, or body mass index, is greater than 40, and
in many cases this is about roughly 100 pounds over your ideal body weight, that’s really all
that’s necessary for you to be medically necessary to have an operation. What that means is that we want to find what
health conditions you have that make you a candidate, a BMI greater than 40 is essentially
all that we would need to tell your insurance company that this is medically necessary. In addition to that, a BMI greater than 35,
roughly 50 to 60 pounds overweight, plus other medical problems related to weight, such as
diabetes, high blood pressure, coronary artery disease, high cholesterol or high levels of
fats in your blood and sleep apnea or other problems breathing, as well as arthritis,
difficulty ambulating, etc., can also be candidacy for surgery as well. I think it’s important to differentiate though
between medical necessity and having a benefit, having the insurance benefit for this operation. Oftentimes insurance company may say, yes
this procedure is medically necessary, but we don’t offer coverage for weight loss surgery. So it’s going to be important for you to find
out if in fact your insurance carrier does provide weight loss surgery as an option for
you. In addition to BMI, it’s also important that
you really understand what bariatric surgery is all about. That you have to understand that this is an
operation which does carry some inherent risk. Depending on you and your medical problems,
age, we may determine what the risk is for you as an individual for your operation. With that being said, under the right conditions,
bariatric surgery is a very safe and effective option for you. In addition, we would like to see that you
are able to change your diet, that you’re able to eat the foods that you need, to have
a safe operation and to be successful long-term. And really it is essential with these operations
to be able to commit to long-term follow-up care. In addition to helping you make the lifestyle
changes and deal well with your operation, we want to make sure that those medical problems
are being followed and get better, that your nutritional values are followed, that the
vitamins you are taking are right, and that we’re doing a good job in your long-term care. One of the best advances we had in bariatric
surgery in the last decade or so is being able to do these operations through a minimally
invasive approach. Instead of making a big incision down the middle of your abdomen,
we’re able to do these operations through several small incisions. What this means for you is that we can do
this operation with less pain, quicker healing, less chances of infections, hernias, and a
lot quicker recovery. But surgeons at Ohio State University have
all been fellowship trained in minimally invasive surgery and have helped pioneer many of the
techniques that are being used today. Here’s a graphic of what the open incision
would look like. It’s usually an incision that goes from your sternum down to your belly
button. You know, if you have to have this operation this way, it’s still a very safe
and effective way to do the operation, and if it’s necessary, the benefits still outweigh
any problems that you would have from the incision, but still better to do it through
minimally invasive technique. Here’s an example of what some of those keyhole
incisions, they’re small little incisions that we make. Most of these operations are
done through five or six little incisions. Again, advantage is you recover a lot quicker
with an operation of this sort versus that big open incision. Despite which operation you have, whether
it’s done through the laparoscopic approach, which greater than 95 percent of our operations
are, or an open operation through the big incision, be assured that the operation on
the inside is exactly the same. We do the operation the same and have the
same outcome inside whether we do it through the traditional approach or through a laparosopic
approach. There are three major types of operations
that we do here at The Ohio State University Medical Center. A roux-en-y gastric bypass, a vertical sleeve
gastrectomy and a lap band surgery.>>NARRATOR: Gastric bypass is a restrictive
and malabsorptive procedure that results in fewer nutrients and calories being absorbed. It reduces food intake by cutting and stapling
the stomach to make a small stomach pouch. The small intestine is cut, and the lower
section is directly attached to the new pouch. Food then passes directly into the lower portion
of the small intestine, bypassing most of the stomach and upper intestines. So again, what you’re left with is a small
pouch about the size of an egg, connected to your small bowel, and that small bowel
is connected with the hole that’s about the size of a dime or so. Both of those components are very important
for a successful weight loss operation. What those two things do is they help make you
feel full a lot quicker than if you don’t have an operation. You have to eat a little bit differently in
that you have to chew up your food real well, eat real slow, and as soon as you feel full
stop. If you don’t, it can hurt, make you feel sick, make you throw up, and in general
will really help train you to eat a lot less food and feel full a lot quicker. This operation may cause you to be sick if
you eat foods that are high in sugar. It’s not that you can’t have any sugar, but once
you eat 10 to 20 grams of sugar, you may get what we call a dumping syndrome, where you
get really bad cramping pain and diarrhea. A little while later you may feel real hot, flushed,
sweaty, feel a little lightheaded or faint even. So if you’re a sweet eater, this may be a
real good operation for you to really help prevent you from eating too many sweets, which
may impact your weight loss and health. The third most common operation we perform,
and the one that is really increasing in numbers in the United States is the sleeve gastrectomy. This is, while it’s the newest of the three
operations, it’s something that’s being done for a long time. Sleeve gastrectomy is a restrictive procedure
that limits food intake by cutting and stapling a thin vertical section of the stomach to
make a smaller, narrower stomach pouch. The remaining larger portion of the stomach
is then permanently removed. Unlike gastric bypass, there is no rerouting of the intestines. However the sleeve gastrectomy involves permanently
removing the large portion of the stomach. And this operation makes it a nice in-between
operation between both the band and the gastric bypass. The second most common operation we perform
right now is the adjustable gastric banding. There are two types of bands available, the
Realize band from Ethicon and the LAP-BAND from Allergan. During a minimally invasive procedure, an
adjustable band is placed around the upper part of the stomach creating a small pouch. The band is connected by thin tubing to an
access port below the skin. Through this port, your surgeon adjusts the LAP-BAND by inflating
or deflating the inner lining with saline. As the band inflates, the stomach outlet becomes
smaller. This helps reduce or restrict the amount of food you eat, and slows the emptying
into the lower stomach, helping you feel full sooner and stay full longer. Again, if you overeat, eat too much, eat too
fast, don’t chew it up well enough, you can get sick, throw up, or feel pain with this
operation. So really again it helps you eat a lot less food. The key to this operation is to recognize
that feeling of fullness and stop eating. Here’s a general comparison between our three
operations. Roux-en-y gastric bypass, sleeve gastrectomy and gastric banding. In general, a gastric bypass will take about
an hour to an hour-and-a-half for us to do laparoscopically or open, and a sleeve takes
about an hour to do. Gastric banding usually takes about 35 minutes. Most patients who have a gastric bypass or
sleeve usually spend two to three days in the hospital. What we’re trying to accomplish
while you’re in the hospital is to get you up moving around pretty well on your own,
drinking enough liquids to keep yourself hydrated, and getting you back on your medications. Very often with lap band surgery, if you don’t
have sleep apnea, we are even able to do this operation as an outpatient. However, for those
of you who prefer or have sleep apnea, we keep patients overnight to monitor them after
having large surgery. In general, we would say that a gastric bypass
and a sleeve gastrectomy is an irreversible operation. In a sleeve, a portion of the stomach
is removed, and once it’s removed we can’t put it back in. While everything stays inside with a roux-en-y
gastric bypass, the operation we say is irreversible, because although we can sew the things back
together, there’s no guarantees that you’ll be normal after the operation. On the other hand, we would say that a lap band
is reversible, because once the band is removed, in just a few weeks, you would be completely
back to normal. Very often having a roux-en-y gastric bypass
and a sleeve, it takes about two to six weeks to recover from the operation. Obviously this is a very individual thing,
oftentimes patients are able to return to light duty and things within two weeks of
the operation. But keep in mind that you’re losing weight very quickly after these operations
and it’s very difficult to get your energy level back. Very often what takes time to recover is one,
learning how to eat again, and two, getting that energy level back where you can make
it through a complete day. With lap band surgery, because you’re not
losing weight as quickly, it’s a little bit easier to recover. Many people are able to
return to work or normal function within 10 days after the operation. With a roux-en-y gastric bypass, we would
expect that you would lose somewhere between 75 and 85 percent of your excess weight. With a sleeve, maybe 65 to 75 percent of your
excess weight. And with a lap band, somewhere between 40
and 70 percent of your excess weight. These are large amounts of weight and what
we mean by excess weight is what you weigh now less what your ideal body weight is, so
what you’re supposed to weigh, losing about three-quarters of that difference in many
cases. Obviously some of the major differences in
what affects weight loss is with the gastric bypass versus a sleeve and gastric banding.
Since because there’s going to be no dumping syndrome or an effect of making you feel sick
after having sugar, with gastric banding or sleeve gastrectomy, sometimes even high calorie
liquids like juices, milkshakes, ice cream, things like that, a little bit easier to beat
these operations with a sleeve or a band versus a gastric bypass that would make you very
sick. In general, because of that, most patients
with a roux-en-y gastric bypass will on average lose more weight than with the other two operations.
A sleeve will tend to lose more weight than a lap band. However, depending on which operation is right
for you, your ability to diet, make lifestyle changes, any of these operations can have
great success. In addition to the weight loss, we see tremendous
improvements in those medical problems that go along with being overweight. Diabetes, for example, is very responsive
to these operations, especially a gastric bypass, but also to a sleeve and a lap band. It’s really incredible to see patients completely
resolve their disease of diabetes and go into remission. If we look at patients who have not had diabetes
for very long, maybe five to ten years or less, who are not yet on insulin, in upwards
of 90 percent of patients after gastric bypass may be completely free of their disease after
a few months. Sleep apnea can also improve to the point
where you don’t need your CPAP or BIPAP anymore. High blood pressure can improve over time.
Cholesterol, LDL, HDL levels may return to normal. And what we see is not only reductions
in heart disease, strokes, and cancers long-term, but people will actually live longer than
those people the same weight that do not have surgery. Obviously, the primary focus of the operation
is to get people to lose large amounts of weight. While these operations can seem relatively
drastic, this is what it takes to have an impact on your weight and health. Obviously, you’re choosing to have an operation
we want to have the largest impact for you, and that’s why these operations go to such
lengths to make it easier for you to lose weight and maintain that weight loss. Like any operation, there’s going to be some
risk. The risk comes from the anesthesia, as well, like any operation you would have,
there’s going to be risks of heart attack, stroke, lung problems, etc. Obviously part
of our medical optimization before the operation and evaluation is to minimize these risks
and get you in your best possible shape. There’s no one risk stratification for every
patient. We will try to individualize this and personalize this for you based upon your
medical problems and health. Blood clots are also a concern. There’s about
a 1 percent risk of getting clots in your legs. We do a lot of things to help prevent
these clots from forming. We put little squeezers on your legs, give you shots of blood thinner,
and most importantly try to get you up moving around as much as possible. With the risk of anesthesia and blood clots,
while it tends to be a little bit higher than in other operations, the operation of having
a gastric bypass or a band or a sleeve is no different for you as an individual if you
were having a gall bladder operation, a colon operation, a hernia operation. The risks go along with you as an individual
and not necessarily due to the operation that you’re having. There are some operations that are related
to the operation. Obviously in the operations like sleeves and bypasses, we’re cutting your
bowel and sewing it back together. In many cases, there is some chance that the
seam where the bowel goes together, there could be a leak, where the food, enzymes,
bacteria that are supposed to stay inside your bowel can leak into your abdomen and
cause infection, pain, inflammation and can cause you to be very sick. Hopefully we can keep these risks less than
1 percent. If you do have one of these complications, it’s almost always we go back to surgery,
look inside, try to fix things, and make you better as quickly as possible. In addition, there’s also complication that’d
lead to bleeding and infection like you would see with all different operations. Mortality is an important concern, dying from
your operation. Fortunately, rates of mortality with these operations are very low, less than
1 percent or a fraction of 1 percent, and are usually related to things that we discussed
before. Heart and lung problems, blood clots, or some serious infectious complication. After hearing about weight loss surgery, you
now know that you’re a candidate for the operation or interested in learning more or are sure
you want to have the operation, there are several things that are required by most insurance
companies as well as our program in order to ensure that you’re a good candidate as
well and have a successful outcome. Every patient will require to have a medical
evaluation. During this evaluation we help try to ensure that you’re in optimal condition
for your operation, that there’s no medical contraindications or reasons to not have an
operation and to help you decide which operation might be best for you. We have some requirements for our program
in that we do not like to operate on patients who are smoking, so we do require that you
be smoke-free for 90 days before the operation. While there’s no automatic weight loss requirement
before the surgery, we certainly encourage patients to lose some weight and get on the
road towards losing weight before they have the operation to really help make this a safer
operation and to ensure that the lifestyle changes you make will help you have a more successful
operation. As a result, everybody is required to have
a dietary evaluation to meet with one of our dieticians, to one, go over how you eat now,
what ways you can help yourself before the operation, to make the changes, so it’s not
such a drastic change, to maybe even help you lose weight before the operation again
to make the operation more successful, and to give you the tools that you need to have
a successful operation after surgery. Everybody is required to have a psychological
evaluation. We certainly encourage everybody to have an evaluation with our psychologist.
He’s very experienced and has done thousands of these evaluations for us, and knows what
we’re looking for to help you be successful with the operation. In addition, we do require some extra educational
counseling to really, really impart on you the knowledge that you need to be successful
with your operation. Like I said earlier, the operation is just
one step in this very long journey towards lifestyle change that should last your lifetime
with overall better health. We hope that the information from this presentation
has helped you decide whether or not bariatric surgery is one of the right options for you.
In no way is this video designed to help you choose which operation you want today, and
even if you want surgery. We just want you to have enough information to decide if this
is something that you can continue to want to pursue. If you’ve decide that weight loss surgery
is not the right option for you, either at this time or ever, we want you to know that
we have other options for you at The Ohio State University Medical Center to help you
lose weight and live healthier, whether it’s through medical weight loss, improved fitness,
improved medical care, we want to provide personalized healthcare to you to help you
live longer, healthier and better.

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