What Is Bariatric Surgery and Is It Right For Me?

Podcast Transcript

Scott Steele:  Butts & Guts, a Cleveland Clinic Podcast, exploring your digestive and surgical health from end to end.

Welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the chairman of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And very pleased to have Dr. John Rodriguez who is the director of surgical endoscopy within the Digestive Disease & Surgery Institute here at the Cleveland Clinic. John, thanks so much for joining us.

John Rodriguez:  Thank you very much for having me.

Scott Steele:  So I'd like to have everybody start out and just give a little bit of your background, where you're from. Where do you train? How did it come to the point that you here at the Cleveland Clinic?

John Rodriguez:  Sure. So I'm originally from Venezuela. I did medical school back home and then I moved abroad to the U.S. because I was looking for kind of better training. Spent a couple of years doing research and then ended up here doing residency and stayed for fellowship. And loved the weather. So stayed a few more years.

Scott Steele:  That's fantastic. And so today we're going to talk a little bit about bariatric surgery. So it gets a lot of kind of lay press and it's all over the media. But let's just go high level first. So what is bariatric surgery and can you talk a little bit about the potential benefits of this procedure?

John Rodriguez:   Sure. So bariatric surgery is a group of operations that are targeted towards treating obesity. And I know you had Scott Butch here I think recently and he was talking about how obesity is really a disease. So bariatric surgery is doing an operation to treat the disease, to treat obesity.

Scott Steele:  So lots of different types of ones. So let's first start off a little bit about what is obesity and what is the criteria for obesity. And then there's a certain criteria you would use that you would say would be somebody that could meet a surgical indication for obesity.

John Rodriguez:   So obesity is pretty much defined by abnormal accumulation of fat. And that usually correlates with increased weight in a group of medical problems that are relating to having obesity as a disease. So there's two components and I think people usually only appreciate one of them, which is being overweight, being obese. And that's defined by something called the body mass index, which is kind of a fancy number that comes from a calculation of your height and your weight.

But that also accompanies a bunch of different medical problems that can be very serious, which we'd like to address as metabolic disease, which are conditions like diabetes, high blood pressure, sleep apnea that are related directly to having obesity. And that's exactly what we're trying to treat. It's not just people having an abnormal weight, having an abnormal accumulation of fat, it's also all these conditions that increase the risk of having severe cardiovascular disease. So your risk of having a heart attack, your risk of having a stroke. And these are all treated by bariatric surgery, so much more than any other medical condition out there.

Scott Steele:  So let's talk about the individual operations themselves. So there's a sleeve gastrectomy, there's a gastric bypass or Roux-en-Y, there's a duodenal switch, a lot of different ones. Can you kind of just give us an overview of the different, more commonly used bariatric operations?

John Rodriguez:   Historically there has been a number of them and some of them have fallen out of favor for different reasons. Right now the two more common operations are the sleeve gastrectomy, which pretty much entails taking the stomach, which is usually the size of a small purse and cutting it in a way that it's shaped like a banana or the sleeve of a shirt. That's where the name comes from. So it doesn't involve rerouting the intestines and it's really a safest operation that we have right now. And the results are very good, very comparable to other operations that have been done for a very long time, like the Roux-en-Y gastric bypass.

Now the Roux-en-Y gastric bypass has two different components. So one is reducing the size of the stomach. So we basically divide the stomach without taking it out and we turn it about the size of a small chicken egg or so. And then we take the intestines and we reroute the intestine so a lot of the food that we eat is not going through the first part of the small bowel called the duodenum, which is where a lot of the different hormones that are involved with problems like diabetes are pretty much signaled by the body. So not only it reduces the size of the stomach, but it also reroutes the contents that we're eating so it doesn't go through that part.

Scott Steele:  So are we really just talking about trying to get people to eat less or is something else going on with these particular operations?

John Rodriguez:   It's a very good question. And right now, there's been a big push from our end, from our society to really change the concept of these operations at not just weight loss operations, but truly metabolic operations. So we like to think about that we're not just reducing the size of the stomach, but there's a lot of changes that happen in the body related to a lot of different hormones that truly define how these operations work. So it's not just helping people eat less. It's also changing the way that the body processes a lot of these foods and the body responds to eating a meal. So yes, there's a lot of different hormones that change. So we decrease hormones that are related to appetite to telling your body that you're eating, you need to store fat. So a lot of it is very complex and we don't completely understand all the mechanisms, but we know that there are a lot of changes that happens with our hormones and we think that that's the strongest way that these operations work.

Scott Steele:  So how do you decide what operation to do with a particular patient? Is it one size fits all or are you using BMI or what are you doing?

John Rodriguez:   So we don't really know and we don't really have a perfect way to help people. I think there's two components to this. A lot of times patients do a lot of research on their own. Then they come looking for a specific operation based on something that they read. And most of the time they're very accurate about what they're reading and what they're looking at. Obviously the top priority in all these things is safety and there's no doubt that the sleeve gastrectomy has gained a lot of traction because it's a safer operation.

Now, when we talk about risks and bariatric surgery, we're talking about very, very small numbers. So even though we say that the risk of a sleeve gastrectomy is half of a bypass for a major complication, we're talking in numbers that are way below 1%, so it's very small, very small difference. But the sleeve gastrectomy, even though it's the most popular operation done almost worldwide right now, it's not for everybody because there's a lot of problems that it doesn't address like gastric reflux. And we know that a lot of patients who have diabetes respond better to a gastric bypass than they do to a sleeve gastrectomy. But overall we try to help patients kind of understand what the benefits are and if they have specific conditions like moderate or severe diabetes or gastric reflux, then we try to guide them one way or the other.

Scott Steele:  John, what type of medical conditions, you mentioned diabetes being one of them are helped out by gastric bypass or by bariatric surgery in general?

John Rodriguez:   So the list is huge. There's a lot of medical conditions that we didn't even know that were related to obesity and we've learned through bariatric surgery that they really respond. But I think the big things that we always like to talk about is obviously diabetes. There's been a lot of research that has shown that bariatric surgery is much better than any other medical treatment. So working with your endocrinologist, getting insulin shots and really strict diets are not as effective as bariatric surgery in helping diabetes. More recently there's been a lot of traction because we learned that hypertension response much better than to bariatric surgery, that medications or even lifestyle modifications.

We know that other conditions such as high cholesterol respond to bariatric surgery very well. Gastric reflux like we mentioned, which is sometimes just related to having obesity, but sometimes it's other complex mechanisms in the bodies or the valve that typically keeps acid from coming up is not working as well as it should.

And we know that an operation like gastric bypass helps that tremendously. If we keep going the list is huge. So we know that peripheral vascular disease response to bariatric surgery, patients that have chronic migraines and they have obesity, they can get better with bariatric surgery. Some patients that have developed adult asthma or respiratory problems respond great. Sleep apnea, which has really gained a lot of popularity recently because of all the negative effects it has in her health and sometimes how challenging it is to diagnose it, response great to bariatric surgery as well.

Scott Steele:  It's probably not to mention all the different problems with joints and even patients effect and how good they feel about themselves and depression and anxiety and some other things.

John Rodriguez:   Absolutely.

Scott Steele:  We got a lot of patients out there that may have had bariatric surgery and they might've had some other procedures and some of the things that we talk about in the past in terms of the ring or one of the different procedures that go in there. Can you talk a little bit about this and if they have had these less commonly performed or in some cases operations that aren't done anymore, what do you tell those patients?

John Rodriguez:   So there's always options and if you go back 10 years or so the band which is  placing a foreign body around the stomach to really decrease the capacity, it was the most popular operations. There's a lot of patients that had these operations done and it doesn't mean there's anything wrong with them. It's not like we're recalling these operations is that we learned that they were not as effective as we originally thought.

So a lot of patients have really been successful and they've done great, but some patients have not. So for all those patients out there who had a bariatric operation that is probably no longer done, there's a lot of options and they're still candidates for a lot of the things that we do nowadays. So you have to be careful because when you had a bariatric operation, the risk of complications is slightly higher. So you have to make sure that you go find a bariatric surgeon who has experience with revisional surgery.

Scott Steele:  John, two questions. How much would a patient kind of standard typically lose or have expected to lose, assuming that they do all the right things with exercise and diet and things go well? And then let's go on the other end of the spectrum. There's some patients out there, we all know that we're different shapes and sizes. Who are, let's face it, have higher rates of morbidity or are in the higher end of the spectrum. Is there anything special that you do with that patient population?

John Rodriguez:   So going into the first part of the question, I think that we have to look at obesity as any other disease. And the more severe it is, the harder it is to treat. So typically we talk about average of excess weight loss. So we look at how much your excess weight is and we look at an average of how much people typically lose. So I would say for an average patient coming in who had a gastric bypass you would expect to lose about 70% to 75% of your excess weight. And that number is maybe a little bit lower for sleeve. So about 70% or so. But it doesn't mean that you can't lose 100% of your weight.

And again, if you don't apply all the other tools that you need to use this in your favor and trying to lose weight, you can actually not lose any weight at all. Or as we know, obesity has a tendency to come back so you can actually regain the weight if you're not careful with some of the other things that need to click in place for you to be successful with weight loss surgery.

Scott Steele:  And so for those patients who maybe a little bit on the higher severity in terms of obesity, do you choose a different operation in those patients?

John Rodriguez:   So sometimes when they have a very high body mass index again, top priority in these operations is safety in an operation, like a gastric bypass or some of the more aggressive ones they could do with switch may not be feasible because it's just too high risk. So sometimes for those patients we use what's called a step or a bridge approach where we do an operation like a sleeve gastrectomy, we help them, we follow them and we look at their weight six months or a year down the road and see how they do. And if they don't get to a point where we're happy and their medical problems are responding we can always go back and convert that sleeve to a more aggressive operation, like a gastric bypass or duodenal switch.

Scott Steele:  So John patients come to the Cleveland Clinic’s Bariatric and Metabolic Institute from across the country and from all over the world for their multidisciplinary care and some of the support systems that you guys are able to provide.  So for those patients that are thinking about coming here, just walk us through what can they expect when they come here? What's a typical office visit like?

John Rodriguez:   So I always tell patients that one of the most common questions that I get are common complaints that I get is when I see them six months a year out is why they didn't do this sooner. And I think people need to understand that this is a process that takes time because we have to make sure that people understand what they're going through and what these operations entail in terms of the changes in their quality of life and what they need to do to be successful. So managing obesity is a multi-disciplinary task. So we have a lot of different people that work together. So the obesity medicine specialists who are doctors that specialize on a medical side of things and they look at obesity and all the medical problems related to that.

We have a group of nutritionist, we have a group of psychologist that help patients get to that point. And ultimately I really have the easiest job in this part because it's just discussing an operation because we already know from everybody, they've seen that they are great candidates for weight loss surgery.

Scott Steele:  So how about the operation itself? So how long does it take? What can they expect in terms of recovery? How quickly can they eat, are there any dietary changes? Is there exercise restrictions? Walk us through that.

John Rodriguez:   So for any kind of surgery, they're all done laparoscopically, which means the tiny incisions. So it really has helped expedite how people recover from the surgeries. And right now we've looked at ways to improve the experience for patients. So we do what's called enhanced recovery or a quick recovery protocol.
So most people, they come in, they're drinking up to two hours before the time of their operation. Usually liquids, they do go on a two week liquid diet before surgery because it helps shrink the liver and makes the operation a lot safer. But for a sleeve gastrectomy it's about an hour, hour and a half, for a gastric bypass about an hour and a half to two hours typically. And after that they stay in the recovery area for a few hours, they go up to the floor and I always tell patients I want them up and walking and moving around and being as active as possible to prevent problems like blood clots and things like that. And they start drinking almost right away. So the first few weeks after bariatric surgery, it's a big change in your body, the way that you process food. So everybody will be on a liquid diet for typically anywhere between two and four weeks.

Everybody progresses a little bit differently. I think the main goal is to really try to stay hydrated and to meet your hydration goals before you start moving up. And there's a lot of kind of back and forth where you try something, you feel it's too much, you have to take a step back. So it does take about four to six weeks for people to really start eating more solid food and the things they like.

Scott Steele:  What are some of the barriers then that people would not get bariatric surgery for those who qualify?

John Rodriguez:   So one of the more common things that we see is patients that have psychological problems or mental health problems that really make it a risk for failure of the operation or interferes with some of the medications that they may have to take. So we have to be very careful with patient selection.

I think that's a most common thing that we see is patients that do have eating disorders and not just obesity is a disease and therefore bariatric surgery is not going to help them. Sometimes we have patients who are just too high risk from a medical standpoint and they need to go through a more extensive process. But we try to work hard and make sure that everybody that could potentially benefit will make it to the point where they can have the operation.

Scott Steele:  So what do you think is on the future for bariatric surgery? Is there something that's on the horizon or something that you can envision that's going to happen over the next one, three, five, 10 years?

John Rodriguez:   We have to understand that obesity is probably the fastest growing disease in the world. And it's also the top killer because we've learned that every single medical problem that is really killing us is related to obesity.

So there's no doubt that there's going to be a lot of progress and we're treating less than 1% of the patients who have obesity with bariatric surgery. So the goal is to make them safer and less invasive. So there's been a lot of push towards innovative therapies that require no surgery at all, but more endoscopic procedures or lower risk procedures and there's a lot of different people that are working on trying to find better and more durable operations that can be done with an endoscope or with no surgery at all. So I think we have to keep our eyes open and see how technology will continue to evolve. I think this is a very complex disease and as we try to treat it more, we also learn more of the challenges related to it.

Scott Steele:  That is absolutely great information. And John, we like to have all of our guests wind up with a couple of quick hitters that are information about you. First of all, what's your favorite sport?

John Rodriguez:   Soccer.

Scott Steele:  And what's your favorite meal?

John Rodriguez:   I shouldn't say that in a bariatric talk, but it's pasta.

Scott Steele:  And what your favorite trip or place that you've been to?

John Rodriguez:   So I like the beach. I grew up in a tropical climate, so I think anywhere that I can go where there's a nice warm weather and there's a beach, I'll be a really happy person.

Scott Steele:  And what's your last non-medical book that you've read?

John Rodriguez:   So I recently read a book called Origins, which was a very provocative book in terms of some of the thought processes that go into, some of the strong psychology related to high performance athletes and people in very stressful environments. So I really enjoyed it, learned a lot. And I actually use a quote in some of my talks that I learned that one of the biggest predictors of how you perform a job is actually what web browser you use.

Scott Steele:  That's fantastic. And so something that finally to finish up that you like here about Cleveland.

John Rodriguez:   My favorite thing about Cleveland is that people, I've been to a lot of places in the United States and I've never been in a place where people are so warm and welcoming as Cleveland.

Scott Steele:  That's fantastic. So if you're considering bariatric weight loss procedure and you would like more information or you have any questions at all, you can access a free treatment guide at clevelandclinic.org/bariatric that's clevelandclinic.org/bariatric, B-A-R-I-A-T-R-I-C. And to make an appointment with a bariatric and metabolic institute specialist, please call 216-445-2224, that's 216-445-2224. John, thanks for joining us on Butts & Guts.

John Rodriguez:  Thank you Scott.

Scott Steele:  That wraps things up here at Cleveland Clinic, until next time. Thanks for listening to Butts & Guts.