At The Forefront Live: Minimally Invasive Weight Loss Surgery

Coming up on At the Forefront Live, obesity is a very challenging condition. People struggle with weight, and are often frustrated with a lack of results. Today on At The Forefront Live, we'll look at bariatric surgery options, and how this can change lives.

Here at UChicago Medicine, bariatric surgery programs are tailored for each individual to get the maximum outcome and benefit. Also today, we'll meet one patient who lost over 80 pounds and gained control over her diabetes. Lynn Yanow has quite a story to tell, and is a different person today because of bariatric surgery. That's next, on At the Forefront Live.

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And welcome to UChicago Medicine, At the Forefront Live. This is your chance to ask our experts your questions by typing in the comments section. We'll get to as many as possible over the next half hour. Remember, this program does not take the place of an actual visit with your physician.

Joining us today, we have two experts in bariatric surgery, Dr. Vivek Prachand and Dr. Mustafa Hussain. Welcome to the program.

Thank you.

First of all, just tell us a little bit about bariatric surgery, in general, what exactly that entails. I think a lot of people, when they think of bariatric surgery, they think, you're just cheating, you're not dieting, you're taking the easy way out. But that's really not the case.

Thank you for the question. Bariatric surgery is basically surgery-- which means manipulation of your organs and your stomach and your intestine-- to really change the way your body perceives hunger and when it feels full. It works by changing your anatomy, but also your physiology, which is the chemical nature of your body's relationship and understanding to food.

And it works by mechanisms that we partially understand, but not fully. And we're definitely working on that. But it's definitely not cheating. It is for people who have tried several things before, but really need additional help from us, in terms of losing weight.

And it's really for people who are looking to lose 75 or 100 pounds. So, Dr. Prachand, why is it called obesity or metabolic surgery, instead of weight loss surgery?

I think that that's a really good question, and I think it's something that's really changed in the field over the last 5 to 10 years. So the emphasis used to really be about weight loss in the past, and so we would really be emphasizing how many pounds people lost, and so forth.

But the American Medical Association, about five years ago, recognized obesity as a disease. And one of the things that we've always recognized with these operations is that, in addition to achieving the weight loss, which is pretty substantial and sustainable, is the impact on the medical problems related to obesity.

And so the importance of thinking about obesity and metabolic surgery is to really keep in mind and emphasize the fact that these operations also have the opportunity to impact all the different medical conditions that come along with obesity, such as diabetes, high blood pressure, high cholesterol, sleep apnea, severe joint problems.

We even see patients who might benefit from transplantation, but are too heavy to qualify to undergo a transplant.

Bariatric surgery can really make a difference. We spoke to one patient who had bariatric surgery here at UChicago Medicine, and here's her story.

And that has drastically changed my life, not to have to take insulin shots. I feel significantly better.

Lynn Yanow was taking four insulin shots a day. It was the only way she could control her diabetes.

I feel better emotionally, physically, and I'm very, very pleased.

Now, Lynn is much lighter, and off most of her medications, including those four insulin shots.

As of today, I've lost 80 pounds in six months. And I'm very excited about that. I would maybe like to lose another 10, but everyone tells me that I should leave it be.

Lynn chose the bariatric program at the University of Chicago Medicine, one of the leading programs in the country. She had the gastric bypass procedure, and is very happy with the results.

The reason that I chose University of Chicago Medicine is because they had a program, Dr. Hussein had a program to go along with the bypass. You had to go to classes, you had to follow up, there was a whole plan.

What differentiates us from everybody else is, I think, our experience, our judgment, and our comprehensive evaluation of patients.

UChicago Medicine offers many options for weight loss. Some of those options include surgery. There's sleeve gastrectomy, gastric bypass, and a procedure for extremely heavy patients-- that is only done at about 1% of the centers in the country-- that's called the duodenal switch.

As an institution, we are providing a wide array of options for patients who are trying to lose weight, whether it's that 10 pounds you need to lose after Christmas, or it's that 200 pounds that you've accumulated over years.

Each of these procedures requires a team approach. The patient will work with several caregivers to assess their challenges and provide solutions. There is also follow-up after the procedure, to make sure the patient has the right support to keep the weight off.

So at a single hospital visit, they will see the surgical team, they will see our bariatric dieticians, as well as our psychologist. And so it's a one-stop shop, if you will.

Weight loss isn't easy, and the patients who participate in the surgical program have struggled with their situations for years prior. But the positive news is there is hope, and it can be a lasting change.

Despite all of our biases, we don't know why people are overweight. It's easy to say they eat more food than they actually burn off. And while that may be true, we don't understand why some patients are more efficient at burning off food than others.

Obesity is a complex issue. It has to do with your genes, what you're eating, what your habits are, what your social behavior is, what your psychological situation is. So it's a complex issue, so it doesn't have just one solution.

Surgery happens to be the most effective way to help people lose weight, but we realize it doesn't function in a vacuum.

Lynn's family is happy with her outcome, as well. It has changed her life, and helped her to a healthier existence.

Since I did the surgery, I feel much better about myself. I am much more confident, I do a lot more things. I do double-takes in the mirror every time I walk a window, every time. I absolutely do not believe that I look like this. And I feel very, very good about it.

It's an interesting story. And it's fascinating to hear the difference in her life, particularly with her diabetes. So to your point just a moment ago, it really does make a significant health difference.

And one thing that you touched upon in the video, Dr. Prachand-- I wanted you to talk maybe a little bit more about this-- is that overall plan. It's not just surgery, but there are many different aspects and different things that people go through before the surgery and after. Talk to us a little bit about how that works, if you will.

Sure. So as was alluded to in the video, we really have a true multidisciplinary program. And what I mean by true, as opposed to virtual, is that we literally have our dieticians and psychologists in the clinic with us.

And we take turns seeing the patients while they're in the clinic office. And then we discuss and confer amongst ourselves to really formulate a good game plan.

So this takes place when patients come in for their initial evaluation. So we identify if there's some particular behaviors or education that we can work on to really get people ready to be successful with surgery. And we also have the same approach in the aftercare.

And all of this is really focused on selecting the patients that we think will have the best chance of success with surgery, and getting the best outcomes that we can have after surgery. So really having that team approach is I think what sets us quite a bit apart.

And it really sets the patients up for success in the future.

Absolutely.

So we want to remind our viewers that we are taking your questions, so type them in the comments section. We'll try to get to as many as possible.

Let's start off talking about the different types of bariatric surgery available. They were mentioned in the video, but if you could tell us a little bit about what they are, and what they entail.

Sure. So there are currently four approved bariatric surgeries that are performed nationwide. We are one of the only centers that actually offers all four types of surgeries.

The most common one being performed these days is something called the sleeve gastrectomy, or vertical sleeve gastrectomy. Some people call it VSG. This is a procedure that's done laparoscopically, which means surgery through very small incisions.

So most of the incisions are about 1/4 of an inch or so. And this can be done with general anesthesia, and most people actually wind up leaving the next day. So the sleeve gastrectomy is a procedure which reduces the size of your stomach by permanently removing a portion of it.

So I like to tell people, if you think of your stomach like a big handbag that you can stuff lots of things into, if you were going somewhere over the weekend. By removing a portion of it, you basically are trimming it down to where just the essentials fit in.

So some people say it's a banana shape, or I like to say from the big handbag, to maybe just like a small purse you would take to a party, or something like that.

And so that reduces the space where you can fit food, but also we've learned that actually impacts some hormones in your body that affect hunger and how full you feel. So it's not that you feel hungry but can't eat, but it actually changes the relationship that you have with food. So that's why it's one of the reasons that it actually works better than restricting yourself on a diet.

So that's currently the most common procedure. Another procedure that's performed, also laparoscopically, or using the small incisions, is called the gastric bypass. Sometimes call it people call it the Roux-en-Y.

This is a procedure that's been performed actually the longest for weight loss, since like the '60s or something like that. And it has a really excellent track record. Because it's been around, there are some stories out there maybe that it was not safe in the past, et cetera.

But this is actually is not true. It's a very safe procedure, likely as safe as all the other procedures. And it has certain advantages over the sleeve. And sometimes we recommended for people with severe heartburn or reflux.

We may also recommend it if you have diabetes on insulin, such as the patient that was highlighted earlier. And it can be quite effective in getting people off the insulin that they're on.

The other procedure is a procedure called the duodenal switch, which is the procedure that we specialize in here at the University of Chicago. Dr. Prachand was actually the person to perform it first, using the minimally invasive techniques here in the Midwest.

And very few centers around the country perform it. It is a little bit more complex procedure, but also has more rewards. The duodenal switch is a procedure that affords you the most weight loss, particularly if you're in the category of people who may need to lose around 200 pounds. And that's people whose BMI-- which is body mass index-- is over 50.

And also, it's very effective for people who have very severe diabetes, that have been diabetic for greater than 10 years on insulin. And can be a very powerful way to treat that metabolic disease, that combination of obesity and diabetes.

The last procedure is something called the laparoscopic adjustable gastric band. Technically we do offer it, but it is a procedure that is becoming sort of less popular these days, mainly because it is a device. It is subject to moving and breaking.

And also we've seen over the last few years that the weight loss is not as effective as some of the other procedures. And so it is a procedure that is approved, but we are actually performing it less frequently, these days.

Now, we are getting questions from viewers. I want to get to those, and try to answer as many as we possibly can during the program. First question, which you pretty much just answered but we'll go ahead and throw it at you again, anyway, when you were talking about the duodenal switch.

This is somebody who says, do you think a person whose BMI is over 50 should think about surgery? And I guess, the question would be, then, what types of surgery should they should they first consider? And either one of you can field that one.

So you mentioned BMI of greater than 50. So again, BMI stands for body mass index. And we get that number by combining height and weight into a formula, and it gives a pretty good estimate of how much extra fat a person has for their height.

It's not a perfect number, and you'll see a lot of news stories and a lot of complaining about BMI. But the reality is that, unless you're an NFL linebacker or a professional athlete, it actually does a pretty decent job of estimating this.

So just to quickly review, a normal BMI is between 20 and 25. And a person is considered obese if their BMI is greater than 30. And so we talk about surgery for obesity when the BMI is 40 or higher, or if it's between 35 and 40 and the person has other significant medical problems related to their obesity, as we mentioned earlier.

So when we're talking about BMI of greater than 50, that's typically somebody who's 150 to 200 pounds overweight. And typically, and frequently associated with that are those other obesity-related medical conditions like diabetes, high blood pressure, and so forth.

So in the past, when gastric bypass was the most common operation performed, say 15, 20 years ago, what was seen quite frequently is that patients who had BMIs greater than 50 or 60, they frequently failed to lose enough weight after they had gastric bypass, or they would regain a significant amount of weight.

And that's really what prompted our interest in performing the duodenal switch, because historically, it seemed to be associated with a greater amount of weight loss. But there really had not been any head to head studies comparing the two operations to determine which is actually more effective for this very difficult-to-treat group of patients with a higher BMI.

So we did the first study comparing not only the weight loss, but the impact on diabetes, high blood pressure, and high cholesterol. And we were the first to find that there was, in fact, a significant advantage for patients with greater than a BMI of 50.

Now, that doesn't mean that every patient with the BMI of greater than 50 should have a duodenal switch. And I think that one of the key things that we really try to convey to our patients when they come for an evaluation, and what we really take most of their time in our conversations and discussions with patients, is figuring out what the right tool is for you, as an individual.

Because there's not one operation that's the best for everyone in all circumstances. And so it's really about finding the right match between the operation and the patient, taking to account the fact that each person has a different amount of weight that they need to lose, each person has different medical conditions that are related to their obesity, different side effects of the operations, and different effectiveness, in terms of weight loss and impact on these medical conditions.

And so that conversation that we have as the surgeon with the patient is really the key.

So we've talked about people with the higher BMI. So we have a question from a viewer, somebody without that level of BMI. And the question is, for someone struggling to lose 25 pounds, would surgery be an option?

Generally, probably not. Again, we don't necessarily go by how much weight you're overweight, but the BMI. So you would have to calculate your BMI. But the minimum BMI is basically 40, which correlates to roughly around 100 pounds for people who are normal height. Or an average height, I should say.

Or if you're a BMI is over 35 and you have a medical condition closely related to obesity, such as diabetes, high blood pressure, high cholesterol, or sleep apnea.

Generally, if you're about 25 pounds overweight, you're probably around a BMI of 30, again, if you're an average height individual. And around that BMI, generally, the first recommendation would be intensive lifestyle modification, which is also the first step for anyone who's trying to lose weight.

So that's, generally, meaning working with a professional, such as a dietician or a medical specialist that works with obesity medicine. Or maybe even a therapist or a psychologist that can help you lose weight. But having those regular visits with professionals really been shown to affect success with people trying to lose weight.

And that's one of the nice things about UChicago Medicine. We do offer services like that, as well, so we can cover the whole range. How safe is bariatric surgery?

So I think that there is a lot of myths and concerns, when it comes to surgical safety with these operations. And again, this, I think, dates back to 20 years ago, when these operations really were considered to be risky. And frankly, there as a lot of high-profile cases in the newspapers, and so forth, as the operations initially started to become more popular.

But over the years, with modifications and techniques and the management of these patients, using laparoscopic approaches, instead of the traditional open incision, which required a pretty large incision extending from the breastbone down to the belly button.

By using these approaches, and really the management of the team, the safety today in centers of excellence, such as ours, is very similar to patients who have gallbladder surgery. Which is to say that it's a very safe operation.

We have more questions coming from our viewers. I've heard hair loss can be a common side effect of bariatric surgery. Is there a way to avoid this, and does it taper off on its own?

This can happen after bariatric surgery, but it can happen also if you're losing weight with any other means. When you do lose a significant amount of weight, particularly quickly, it is the body's natural response to sort of make sure it's not wasting resources, if you will.

And not that hair is a waste of a resource, but basically, it does require protein from your body to make hair. So when you're in that initial period of rapid weight loss, your body may say, let's just see what's going on. Make sure we have enough nutrients for essential functions.

So it may shut down new hair growth for a little bit, and that may come off as seeing that you're losing hair. Generally, this is temporary and fully recoverable. And it generally is not significant to a point where others would notice, but you may notice that your hair is thinning.

Our dieticians, who are nutritional specialists that we work with, are very good at counseling our patients through this period, and making sure that they keep up with the appropriate protein and vitamin recommendations that can really limit the amount of hair loss that they experience, and certainly help with the hair regrow period.

We've got a follow-up question to that. Let's talk a little bit about the vitamins and supplements and things that people will take after a surgery like this. How long does that go on, and how significant is that?

So with all of the operations that we do, taking vitamins is something that's necessary after surgery forever. Each of the operations is slightly different, in terms of the way that the body absorbs and handles different nutrients and vitamins, but in all cases, because of that reduction in appetite and because there's less food being taken in, if you don't get enough in and if your body's not absorbing in the way that it had been previously, you're at risk of developing deficiencies.

So taking vitamins every day is an important part of being as successful as you can be after surgery. I like to tell patients, you wouldn't want to get a transplant operation and then not take your immune suppression medication afterwards. And you have to almost look at vitamins in the same way, after you have these operations.

One of the common criticisms that people will make when they talk about bariatric surgery is, oh, people will just gain the weight back. Is that true? Or what do we do now to try to prevent that?

So if you look at, let's say 100 people who've had bariatric surgery, the majority of those patients-- let's say 5, 10 years afterwards-- will be down from the initial point that they had surgery.

So let's say, if they had 100 pounds to lose, the majority of them-- that's over 50% of those patients-- will be down 60, 70, 80 pounds. It is very normal, though, after the first year or two after the surgery, to regain a little bit of weight.

I tell my patients it's kind of like setting your thermostat. You should think of surgery as resetting your body's thermostat of where the normal weight will be. So initially, you will lose a lot of weight, and your body will then find its new steady state.

And then everybody regains just a little bit of weight back. And then it's our job working with the patients to make sure that that little bit of weight we gain, which is normal, stays at that level, and doesn't you know skyrocket back so people are getting excessive amounts of weight back.

There are some patients that do gain a significant amount of weight back, usually not to the point where they start off at. But if you if they've lost like 80 pounds, they may regain back 30, 40 pounds, which is not a result that we wanted. And we definitely work with them to limit that.

A major way to prevent that from happening is close follow-up with us, close follow-up with our dieticians, and a continued understanding that surgery, as we talked about earlier, is not the easy way out. It is basically a tool to help you continue to do what you know you should have been doing, which is modifying your diet, increasing your physical activity, and the everything else that we normally talk about with weight loss.

So here's another question right along those lines from a viewer. For those of us who have had gastric sleeve surgery-- this person was June of 2014-- they've gained some weight back. They want some motivation or suggestions to kind of get back on track. What would you tell somebody to jumpstart that process again, and how would you help?

Sure. So the way that I would begin with that patient is make sure that they go in to see their surgeon, and re-engage with the program. Oftentimes, patients will sort of drift away because of job changes, or they move and so forth. And if they can come back and see their team, that first step can help substantially.

Typically, what we would do in that sort of circumstance is make sure that there's not any sort of anatomic problem that might be contributing to the weight re-gain. And at the same time, we would have a full assessment by our dieticians and our psychologists to make sure that the diet hasn't drifted or shifted in a negative direction.

And really kind of re-educating and just getting back on track. And to be honest, I think that that's really where the value of the long-term follow-up comes in. Because the reality is that nobody can be perfect every single day, multiple times a day for the rest of their lives.

We kind of use a ratio of, if you do the right thing 80%, 85% of the time, you're going to be fine. And life happens. And there's things that happen with regards to employment, relationships, and so forth, and stresses that can lead to people kind of getting off the track a little bit.

And we're here for our patients to really get them redirected and re-engaged and moving forward again.

Here's another viewer question. Not sure why this one is being asked, but I'm going to go go ahead and throw it out anyway. They want to know what form of vitamins would they take. Chewable, gummy, or pills?

That's actually a great question. After bariatric surgery, we are, generally, altering the anatomy. So the way some things are absorbed or taken up by your body is a little different. And that's partially how the surgeries work.

So after certain procedures, we do counsel our patients to take vitamins that are absorbed better. Sometimes the gummy vitamins, those are vitamins that can basically dissolve in water. You chew them in your saliva or spit, and they dissolve and you can swallow them. And that's adequate for some of the vitamins.

But some vitamins actually are not well absorbed in that format, and we may then recommend different combinations or formulations of vitamins that are better absorbed. Some vitamins, you may notice, come in a little droplet of oil, and those may not be good after certain procedures.

So we and our dieticians come up with an individualized plan for each patient based upon the surgery they had, and also, actually, their pre-vitamin levels.

You may have noticed in Chicago that it's actually pretty cloudy today, so that means vitamin D levels are low. And actually, most people, actually even before surgery, come in with some low vitamin levels.

And what we do is we actually, before your surgery, check all those levels, come up with an individualized plan about what your vitamin regimen should be based on that and the surgery you've had.

So each patient will vary somewhat in what they'll have to take, and how they'll have to take it. So here's an interesting question. How do you make sure that people don't lose too much weight? I don't know if that's ever a concern with patients, but how would you handle that?

Well, I think that it is a realistic concern. I think patients all have in their minds sort of what they would consider to be a target or a goal weight, if you will. And I would say that the first step is you have the write operation to begin with.

As I said earlier, there's not one operation that's best for everyone in all circumstances. And it's really that initial determination and decision that we come together with the patient about the surgery a choice that will significantly determine, not only the risk of losing too much weight or also not losing enough weight. So really finding that sweet spot in between.

So are there certain foods or drinks that will be off limits after the surgery?

That's a great question. So again, it sort of depends on the type of procedure you've had. In general, many people come in thinking that, oh, gosh, I'm going to have to eat baby food for the rest of my life, or just drink liquids.

That's actually not true at all. Our goal is to get you to eat normal, healthy food again. And about three months after the surgery, consistency-wise, there's really no restriction. So you can eat vegetables again, you can eat meat again, all those things.

But we do counsel you on the types of foods you should be avoiding, and foods that work against the weight loss. So a high-carbohydrate diet, that's, again, a lot of starches, flour rice, pasta, potatoes. Anything that has that sort of white color and consistency is generally to be avoided, mainly for weight loss.

Sugars, sugary things, sweet things. Again, works against weight loss, but sometimes can make you feel ill after certain types of surgery. So if you eat something that's very sweet or high concentrated in sugar, that, again, may not agree with you, and also is not good for weight loss.

Generally, we tell people to avoid carbonated beverages. That's things like soda, beer, pop. Again, because as that gas expands in the stomach that maybe a little smaller, or in your intestine, that can be uncomfortable and not make you feel well.

So I would say things to be avoided are carbonated beverages, high sugars, and then high-carbohydrate foods.

We're about out of time, but I do want to ask this one last question, and it's concerning insurance. Obviously, if you're going to have a procedure done, there's always some concern from the patient's standpoint on whether or not something like this would be covered by insurance. Can you speak to that a little bit?

Yeah. So I think that there's a perception out there that these operations are cosmetic, and in many cases, cosmetic operations are not covered by insurance. But I think it's really important to understand that these obesity and metabolic operations are not cosmetic.

As Dr. Hussain alluded to, these things actually change the physiology of the body and contribute to the weight loss, as well as to the improvement in the medical conditions related to obesity.

And because of that medical aspect, most insurance companies actually do cover obesity surgery. Although the individual patient has to look at their plan to see if it's a covered benefit.

It turns out that, with the reduction in medications and the overall gain and health that takes place after these operations in the long run, it's actually a cost savings to the health care system for individuals to undergo these operations.

That makes perfect sense. Well, gentlemen, thank you very much. That was great.

Thank you.

Appreciate it. That's all the time we have for At the Forefront Live. Thanks to our guests for their participation in today's program, and thanks to you for watching and submitting questions.

If you want more information about bariatric surgery, please visit our website site at uchicagomedicine.org, or you can call 888-340-9790.

Join us for our next At the Forefront Live, where we learn about minimally invasive robotic cardiac surgery. That's Monday, February 4th. Also check out our Facebook page for future At the Forefront Live dates and subjects.

Thanks for watching, and have a great week.

What are the results of a minimally invasive weight loss surgery, and does the weight stay off? Can bariatric surgery reduce the effects of diabetes? Mustafa Hussain, MD, and Vivek Prachand, MD, talk about minimally invasive surgery for weight loss in this episode of At the Forefront Live.

How do you decide which type of bariatric surgery is right for you?

There's not one operation that's the best for everyone in all circumstances. It's really about finding the right match between the operation and the patient. We take into account the fact that each person has a different amount of weight to lose, and each person has different medical conditions related to their obesity. Also, each operation has different side effects and different effectiveness, in terms of weight loss and impact on these medical conditions. So, that conversation between the surgeon and the patient is really key. Learn more about the different weight loss surgery options.

Is bariatric surgery covered by insurance?

There's a perception out there that these operations are cosmetic, and in many cases, cosmetic operations are not covered by insurance. But it's really important to understand that these obesity and metabolic operations are not cosmetic. These procedures actually change the physiology of the body and contribute to the weight loss, as well as to the improvement in the medical conditions related to obesity. Because of that medical aspect, most insurance companies actually do cover obesity surgery. Although the individual patient has to look at their plan to see if it's a covered benefit. It turns out that, with the reduction in medications and the overall gain and health that takes place after these operations in the long run, it's actually a cost savings to the health care system for individuals to undergo these operations.

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Attend an information session to learn more about our surgical weight loss program. We offer both online webinars and in-person information sessions. 

To register for either in-person session or for the online webinar, please call 773-702-1618.

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