New Guidelines in Bariatric Surgery

Podcast Transcript

Dr. Scott Steele: Butts and Guts, A Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at Cleveland Clinic in beautiful Cleveland, Ohio. So, we're pleased here today to welcome Dr. Ali Aminian, the Director of the Bariatric and Metabolic Institute here at Cleveland Clinic. He is one of the world's leaders and is published in some of the highest-quality peer-review journals on Bariatrics. Ali, welcome to Butts and Guts.

Dr. Ali Aminian: Thank you, Dr. Steele, for the invitation and kind introduction.

Dr. Scott Steele: So, we're going to talk a little bit about the new guidelines in bariatric surgery, but before we jump into that, for all of our longtime listeners, we want to know a little bit more about you. So why don't you tell us a little bit more about your background, where you came from, where you trained, and how did it come to the point that you're here at Cleveland Clinic?

Dr. Ali Aminian: Oh yeah, very good. So, I'm bariatric surgeon at Cleveland Clinic, Professor of Surgery at the Lerner College of Medicine. I was born and raised in Iran and have been with Cleveland Clinic for more than 10 years now.

Dr. Scott Steele: So, let's start a little bit of a high level first. What is bariatric surgery and when would someone even consider it or even meet qualifications for it?

Dr. Ali Aminian: So bariatric surgery is actually weight loss surgery or metabolic surgeries. These words can be used interchangeably. So, these basically are procedures that influence metabolism by inducing weight loss and changing GI physiology. These procedures are the most effective treatment for obesity. They also have profound metabolic effects. For example, they improve diabetes in a large number of patients.

Dr. Scott Steele: So, as we talk a little bit about the qualifications for bariatric surgery, when is a person meeting those qualifications, and more importantly, as to today's topic, can you tell us a little bit more about the changes in the guidelines that have expanded eligibility into it?

Dr. Ali Aminian: Yeah. So, historically, bariatric surgery had been reserved for patients with severe form of obesity as the last resource. But in the past 20 years or so, the field has progressed significantly. Now, we have much safer, much more effective operations to offer. Over the years, we also learned that we need to treat obesity aggressively, because obesity is a devastating disease and is the root cause of many other medical conditions, like diabetes, fatty liver, heart disease. So, that led to recent changes in the guidelines. Based on the new guidelines, patients with mild to moderate obesity are also good candidates for bariatric surgery. So, it's not just for patients with severe form of disease.

Dr. Scott Steele: Can you talk a little bit about what the most common bariatric surgery procedures are? And really, how does bariatric surgery work?

Dr. Ali Aminian: The two most common bariatric operations are gastric sleeve and gastric bypass. So, we do operations for majority of cases with laparoscopy or robot. So basically, we go inside the abdomen through five or six small incisions and do the surgery. For the gastric sleeve, we remove about 80-85% of the stomach. So, imagine the shape of the stomach inside the belly looks like a football. After surgery can look like a banana, a narrow tubular stomach. So, we remove about 80-85% of the stomach. For the gastric bypass again, we go inside the belly through five or six small holes. We disconnect the stomach on the top part to make a small pouch, and then we bring the loop of small intestine and connect to that pouch. So that means when patients take food, foods go through their esophagus to that small pouch, and it'll be shifted directly to the small intestine. So, we bypass about 90 to 95 percent of their stomach.

So, the difference between the sleeve and bypass is that the sleeve will remove part of their stomach. In the gastric bypass, we don't remove anything, we reroute the stomach. So, on the sleeve, we operate only on the stomach. The gastric bypass, we operate both on the stomach and the small intestine. So, both are extremely safe, both are extremely effective. Sleeve is a bit safer. Gastric bypass is a bit more effective. So, they help patients to lose large amount of weight, and they improve the metabolic profile of patients.

Dr. Scott Steele: So, what's the recovery like? And then can you talk a little bit about more what is the expected weight loss after bariatric surgery. And what's the timeline of that weight loss?

Dr. Ali Aminian: So, recovery is fast. So, these procedures are extremely safe. The risk of having complications, Scott, is about 5 percent. That means out of a hundred patients, only five may develop adverse events, including bleeding, infection, anesthesia problem, blood clot, heart attack, altogether. So, 95 percent of patients won't have any issues. Risk of dying from surgery is about one out of a thousand operations. So, these are extremely safe operations. So, it takes about two hours to do the surgery. Patients typically stay in hospital for one night, maybe two nights, and it usually takes about two or three weeks to recover. So, after two or three weeks, patients get back to their normal life.

In terms of weight loss, typically patients lose about one third of their body weight. For example, in a patient who is 300 pounds, that means weight after surgery would be around 200 pounds, and it usually happens in the first eight to 12 months after surgery. Most of the weight that patient loses can happen in the first eight to 12 months after surgery, and patients are able to keep the weight off for the most part for a very long period of time.

Dr. Scott Steele: So how does weight loss surgery impact the patient's life and quality of life?

Dr. Ali Aminian: So, a lot. As we just discussed, patients lose a large amount of weight and are able to keep the weight off for a very long period of time. Almost all comorbidities that are associated with obesity, like diabetes, high blood pressure, risk of heart attack, stroke, kidney disease, fatty liver, sleep apnea, joint pain - I can give you a list of 200 medical problems - significantly improve after the surgery. Patient will have more energy, will be more mobile, more active. They enjoy their lives much better.

Surgery also can increase the lifespan. Overall surgery can provide an average of six additional years to live for patients, which is a very large effect. So, imagine Scott, I operate on a patient today and I give her or him a chance to live six years longer. So that's a huge benefit. Actually, in patients with diabetes who undergo surgery, that's even longer than six years; close to nine years of additional years to live, which is very large.

Dr. Scott Steele: So now we're going to jump a little bit into a part that we call “Truth or Myth.” So, truth or myth: revision surgery is sometimes needed after bariatric procedures.

Dr. Ali Aminian: Well, it's truth. Overall, revisional surgery is needed in about 5 percent of patients who had bariatric surgery. So, 95 percent won't need any additional procedures. So, we have two broad categories of revisional surgery. Corrective operations to fix complications of first operation, and conversion of one surgery to another bariatric surgery to help a patient to lose more weight. But again, 95 percent of patients don't need any further operations.

Dr. Scott Steele: So, when should a patient avoid bariatric surgery?

Dr. Ali Aminian: Well, a patient with active psychosis, history of substance abuse, heavy drinkers, are not candidate for bariatric surgery. We also don't operate in patients with dementia, active cancer or patient with short life expectancy. Additionally, patients who are unable or not willing to make required lifestyle changes after surgery are also not good candidates.

Dr. Scott Steele: So, are there any nonsurgical procedures available for patients?

Dr. Ali Aminian: Yeah, absolutely. New endoscopy procedures, new weight loss medications, have emerged in the past few years, and some patients respond well to them.

Dr. Scott Steele: How would you know when to go with the non-operative ones versus the operative ones? Is it just a matter of what their BMI is or is there more to it?

Dr. Ali Aminian: Yeah, BMI is important. If the patient has only a mild form of obesity, those non-operative interventions or medications are really helpful, but when the patients have a severe form of obesity, if the patient is 300 pounds, or 350 pounds, 400 pounds, they usually need very powerful tools to help them to lose weight, and bariatric surgery can provide that tool.

The other factor that we consider is the surgical risk, or operative risk. If the patient is high risk for surgical intervention, then non-surgical interventions or medications play a significant role. Patient desire and patient goals are also important. So, we need to make a shared decision with patient, talk about different options, and choose the best option for a patient.

Dr. Scott Steele: So, what's on the horizons for the next steps in terms of weight loss surgery, metabolic surgery, all the things we've been discussing today?

Dr. Ali Aminian: Very good question, Scott. So, I think in future we will learn how to use all available tools in our toolbox to treat a patient with disease of obesity. Let me explain this further, Scott, for you and for the listeners. In a patient with heart disease, lifestyle changes are important. Some patients with heart disease require medication. Some patients require stint placement. Some benefits from open-heart surgery, but many patients need a combination of them or a patient with a cancer. A combination of surgery, chemo, radiotherapy, immunotherapy, or even hormone therapy is usually used. So, we need to follow the same concept when we address obesity. Obesity is a chronic, progressive disease which require lifelong treatment. I think in the future we will learn how to combine different options to have better and more durable results.

Dr. Scott Steele: What's a final kind of take-home message, if you will, as we talk about this program for our listeners?

Dr. Ali Aminian: My final take-home message is about the impact of obesity on patient life and broadly on society. So, by 2030, only eight years from now, one out of two Americans will have obesity. One out of four will have severe obesity, which is unbelievable. Only eight years from now. So, obesity is the root cause of numerous devastating diseases. But the good news is that health consequences of obesity are reversible. If we help patients to lose substantial weight and keep the data for a long period of time, we can reverse or prevent health consequences of obesity, and that's really important. So, we need to work together, use all the available tools that we have, including medications, endoscopy procedures, lifestyle changes, and bariatric surgery to tackle the obesity. Otherwise, it is going to get worse, and patients can hurt from this disease and health consequences of this disease.

Dr. Scott Steele: That's great information, and as we kind of round this out, it's time for our quick hitters where we get to know you a little bit better. So, what is your favorite food?

Dr. Ali Aminian: My favorite food is kebab. Iranian kebab.

Dr. Scott Steele: Now is that lamb?

Dr. Ali Aminian: That's lamb. Correct.

Dr. Scott Steele: Fantastic. All right. What's your favorite sport to watch and to play?

Dr. Ali Aminian: I like soccer. I like both watching and playing soccer.

Dr. Scott Steele: Fantastic. And tell us about one place that you've said, "You know what, this is a place where everybody should travel to." One of the great sites that you've been.

Dr. Ali Aminian: I like Orlando very much. The parks, teen parks, I enjoy a lot there. When I go there with my daughters, with family, we really enjoy being there. So, that detaches us from reality for a few days, which is very good.

Dr. Scott Steele: Absolutely. Absolutely. And then tell us, you've come from Iran, so what is one of the things that you like about living here in Northeast Ohio?

Dr. Ali Aminian: So, I like the freedom here and I like the four seasons here, and Cleveland Clinic is a very good place to work with all you guys around us.

Dr. Scott Steele: Fantastic. T to learn more about the Bariatric and Metabolic Institute at the Cleveland Clinic, please call (216) 445-2224. That's (216) 445-2224. You can also visit clevelandclinic.org/bariatrics for more information about bariatric surgery at the Cleveland Clinic. Again, that's clevelandclinic.org/bariatrics. Dr. Aminian, thanks so much again for joining us on Butts and Guts.

Dr. Ali Aminian: Thanks so much, Scott.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.