Reducing Bariatric Surgery Risks During COVID-19: Expert Q&A

[MUSIC PLAYING] Obesity and the related problems of diabetes and hypertension are among the biggest risk factors for COVID-19, prompting many patients to turn to medical procedures that induce weight loss. Surgeons, Dr. Mustafa Hussain, Dr. Vivek Prachand, and Dr. Yalini Vigneswaran join us to answer your questions about the benefits of weight loss surgery, minimally invasive options, and other resources offered at UChicago Medicine.

And as always, we'll take your questions live. That's coming up right now on At the Forefront Live.

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And as always, we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. And let's start off with having our surgeons introduce themselves, and tell us a little bit about what you do here at UChicago Medicine. And Dr. Prachand, you're on my immediate left. And everything's backwards on the screen. But you're on my immediate left, so we will start with you.

Hi. Thanks for having me. I'm the Vivek Prachand. I'm Professor of Surgery. I do advanced minimally invasive and obesity surgery, and I'm the Chief Quality Officer for the Department as well.

Great. And Dr. Hussein?

Yes. Thanks for having us on again. I'm Mustafa Hussain. I'm the director of the bariatric surgery program. I'm an Associate Professor of Surgery. I also do advanced minimally invasive surgery for the upper GI tract and hernia surgery. And also an Associate Program Director, which means that I'm pretty involved with the residency application.

And Dr. Vigneswaran is joining us, but she's joining us in a little different way. We actually taped her section, because I believe she's going to be in surgery, potentially, throughout the show. So we didn't want to derail that at all, obviously.

So let's just go ahead and start off. And we want to remind our viewers, of course, just ask your questions. Type them in. We'll get to as many as possible, as we can, over the next half hour. And Dr. Hussain, I'm going to start with you. And if you can tell us a little bit about the types of weight loss surgeries.

Sure. Currently, there are what's considered to be four approved weight loss, or metabolic surgery procedures. The most common one we perform is the sleeve gastrectomy, which is basically, if you think of your stomach as a large reservoir where, when you eat, it grinds up the food. It's making that reservoir smaller by permanently removing a portion of it.

And that's generally considered the most popular procedure. The average weight loss for that is about 50% to 60% of your excess body weight. And for most people, that turns out to be somewhere between 50 and 100 pounds, depending on their initial weight.

The next procedure is the gastric bypass, and that's a procedure where your stomach is divided into two unequal portions. A small pouch, and the remainder of your stomach is not removed, it's left in place. And that small pouch is connected directly to your intestine.

The weight loss with that is slightly higher, so you can lose somewhere between 75 to 150-plus pounds, or about 60% to 70% of your excess body weight. And that procedure is particularly useful if you suffer from other medical conditions such as heartburn, reflux, and diabetes.

The third procedure is the duodenal switch-- your biliopancreatic diversion duodenal switch. And that is a procedure where we also make your stomach smaller by permanently removing a portion of it, and bypass a certain portion of your intestine.

And that is our most powerful tool to help you lose the most amount of weight possible, and also keep it off for the longest amount of time possible. It's also a very powerful tool to treat, and sometimes eliminate diabetes. And because it's a powerful tool, it can be a complex procedure to perform. So we can actually break that up into three different sections, depending on the patient's risk factors.

And the last procedure is the lap band, which is actually not commonly performed anymore, largely because the weight loss was not as significant as some of the other procedures. And the lap band device can also be subject to failure, and sometimes needs to be removed. And actually, our center specializes in removing the band and converting those patients to other procedures if needed.

And I understand the technology has changed pretty dramatically. Over the past few years, we just get better and better with the services, obviously, that we provide. Now Dr. Prachand, I'm kind of curious. We talked a little bit in the intro about obesity and diabetes that are being risks for COVID. Can you talk to us a little bit about that and how weight loss surgery works in that area? Because I think a lot of people are-- and rightfully so-- worried about COVID, and they're thinking about losing weight.

Absolutely. And certainly, in the media, I think that a lot of figures have pointed out the fact that people who have pre-existing medical conditions are at higher risk of having complications related to COVID. And interestingly, as more and more data has become available, obesity seems to be probably the highest risk, in terms of having bad outcomes with COVID-- meaning hospitalization, intubation, and even dying from COVID infection.

So if you take a step back and think about the US population, almost four in 10 individuals have obesity, and 10% of the population-- one in 10-- actually has severe obesity. And if you look at the risk of dying from COVID infection, if you're a body mass index, or BMI, is between 40 and 45-- which is roughly 100 pounds overweight-- the risk of dying is almost twice as high as a person of normal weight who has a COVID infection. And if the BMI is greater than 45-- and that's typically the type of BMI of patients that we perform surgical treatment for-- the risk of dying related to COVID is quadruple that of a normal weight individual.

And I think that the reasons for that are multiple. Certainly, having obesity makes it harder to breathe. And even treating COVID-- you know, you may have heard in the news of strategies like prone ventilation, where the patient is turned on their stomach to help with breathing, if they're struggling with breathing-- that's more difficult to do. And it's less effective in individuals who have severe obesity.

We know that obesity is also associated with inflammation, and inflammation is one of the things that leads to complications, and even dying from COVID. And so one of the things that it's important to take into consideration is perhaps, because we know that the pandemic, unfortunately, is going to be with us for a period of time, maybe there are ways to help to reduce the risk. Given the fact that infections are, unfortunately, quite common, that if an individual does get infected, they're at less risk of having some of these complications and having poor outcomes related to COVID-19.

Interesting. Now we do have questions that are coming in from viewers already. We're going to get to a couple of those in just a moment. But I do want to get to the sound bite with Dr. Vigneswaran first. And we asked Dr. Vigneswaran who was the ideal candidate for bariatric surgery.

There's actually quite a few patients that can be the ideal candidate for bariatric surgery. We now understand, as a medical field, that obesity is a disease-- a medical disease-- and that many patients can benefit from surgery. And so to know which patients will have the best outcome, or most benefit from surgery, we use BMI, or body mass index, to identify those patients.

And as you all know, BMI is calculated from height and weight. You can Google BMI calculator to calculate your BMI. And so anyone with a BMI greater than 40 is a candidate-- is an ideal candidate for bariatric surgery. Or any patient with a BMI of 35 or greater, and also has some sort of obesity-related disease, such as diabetes, hypertension, sleep apnea, osteoarthritis, is also an ideal candidate for bariatric surgery.

So actually, there is a large population of patients that can qualify, and would be a great candidate for bariatric surgery.

Great. So Dr. Hussain, this next question is for you. And this is actually, apparently, coming in from one of your patients. And this person wrote that they had an appointment with you last week, and they were recommended bypass because of reflux and diabetes. And their question is, would the whole stomach then be taken out?

No. So with the gastric bypass, the stomach is not removed. As the name implies, it's a bypass. So the food goes from your food pipe, just to the top portion of your stomach, and then bypasses the majority of your stomach and goes directly into your small intestine. That bypassed stomach, it no longer sees food, but still makes digestive juices, acids, that are allowed to drain back into your intestines. So it's not removed.

Great. Another question-- actually, more of a comment from a viewer. And they basically-- they are saying that-- it looks like Dr. Alverdy did their surgery 13 years ago. They lost 200 pounds and they've kept it off. So congratulations to you. That's very exciting.

Another question from a viewer. I was only insulin before my surgery, off insulin within a few weeks. 13 years later, and still no diabetes. So more positive comments, not really a question. But that's an excellent comment and excellent outcome.

Now we also talked to a patient-- and Dr. Prachand, I believe you said before the program that this was one of your patients. And this is a fellow named Brian Bates. He's actually in London, so we did the interview with him in London. Can you talk to us a little bit about his procedure? And then we'll play one of his sound bites when he talks about the quality of care here at UCM.

Sure. So I think Dr. Hussain did a really nice job of explaining what the different operations are that we perform at the University of Chicago. And Mr. Bates underwent a procedure called the duodenal switch operation, which is probably the most powerful tool that we have for treating patients with particularly severe obesity, or particularly severe diabetes.

Interestingly, in Mr. Bates case, his obesity was not as severe. But it was the procedure that he really wanted to have, and so we had a long discussion about whether or not it was the right operation for him. And I think it really highlights the fact that we really individualize our conversations and discussions with patients in terms of which operation is the right operation for that person, as an individual.

Because each operation is different in terms of how much weight an individual can lose. It has different impact on medical problems related to obesity, and different lifestyle implications as well. And our philosophy is that whenever possible, your first operation should be your best operation, and hopefully your only operation.

Great. Now let's go ahead and roll that sound bite, John, with Brian Bates, when he talks a little bit about the quality of care that he received here at the UChicago Medicine.

I'm from Chicago, so I knew the quality of care from friends of mine who've gone for care at the University of Chicago hospital. I can't describe how great it is. I mean, I tease Dr. Prachand, the day of surgery, it was like checking into the Four Seasons Hotel. I've never really had that kind of experience with a hospital.

The team there is still-- I'm still in regular contact with them. That's another thing that I am unbelievably impressed with. Jessica, and Angela, and the rest of the team there are very connected. And they want to help you figure out why, for instance, I'm not absorbing enough vitamin A. They're always there to answer questions.

And as I say, it's been three years-- this isn't yesterday. So I can't say enough good things about that. That's something that you just don't have in most places.

Well we like to hear that. That's pretty impressive, really. And for him to be three years out, and obviously he's kept it off. He looks great. So that's obviously changed his outlook on life, and certainly his health, in a big way.

So more questions from viewers. So I don't know who wants to take this one, but I'm just going to throw this out there. Is controlled hypertension a risk factor for COVID-19, or only uncontrolled hypertension? That's kind of a general question, but I don't know if one of you can weigh in on that one.

I can take that. Hypertension is certainly a risk factor. It doesn't seem to be quite as significant as diabetes. So even if it's well controlled, it usually is because of medications and so-forth that have to be used, and alter, and improve the underlying condition. But just having hypertension, even if it's controlled, is a risk factor.

Great. Dr. Hussain, another question from a viewer. Can the VSG-- vertical sleeve gastrectomy-- be converted to bypass, or would duodenal switch be the better option?

Yeah. That's a great question. So a sleeve gastrectomy is our most popular procedure, and it can be quite successful for many people. Some people find they still want to lose more weight a couple of years afterwards. And so you know, we do specialize in converting those patients to other procedures if it's appropriate.

So the first step would be to make sure that we re-engage you with our dietary team, and our support groups, et cetera, to make sure that there is nothing you can do without surgery to help you lose weight. Because of course we want you to be successful with the sleeve. But in some cases, patients do need to lose more weight, or they have other medical conditions that are not resolving with the amount of weight that they have lost.

So for most people, weight loss, or improvement in diabetes, or other metabolic diseases such as cholesterol, or liver disease-- if that's your main goal, the duodenal switch would probably be the best option because that gives you that powerful metabolic reversal of many of those conditions. And it also avoids going back in the area of where you've already had surgery. So we don't go back to manipulate your stomach, which has already had surgery with a sleeve gastrectomy.

But some patients, after sleeve gastrectomy, can develop very significant reflux. Reflux and heartburn is something that we screen for prior to having any of these procedures. And if you suffer from reflux beforehand, perhaps sleeve is not the best option for you. Or if you develop reflux after the sleeve, those patients can then be converted to a gastric bypass, which very frequently eliminates the reflux, and does add some additional weight loss. But not as much as with the duodenal switch.

Great. Another-- this is a comment from a viewer. I'm excited to be having surgery with Dr. Prachand. So we ought to start a fan club for you guys. You're getting a lot of really positive comments, which we love. So that's awesome, and thank you for those nice comments.

This is a sound bite that we want to play now with Dr. Vigneswaran talking about the risks of bariatric and other weight loss surgeries. That's a question that we received earlier. So let's go and roll that one, and see what Dr. Vigneswaran has to say.

Good question. A lot of patients ask, when they come to see us for surgery, what are the risks? And what I tell them is that bariatric surgery is very safe. In fact, it's safer than having your gallbladder removed, or even having your knee replaced. That's for several reasons. We do our surgery through small incisions. It's all done minimally invasive. So very safe procedure, itself.

And then when you see us, you go through a very thorough medical work-up before you even go for surgery. And so we make sure that your body is ready, and safe to undergo an operation. So it's an extremely safe operation.

Another question from a viewer. Are there long-term physical side effects after duodenal sleeve surgery, such as absorption issues, things like that?

Yes. Sure. I can take that. Sure. So there is-- with these operations, and particularly with the duodenal switch, or the DS procedure, there is a change in the way that your body absorbs vitamins, and nutrients, and so-forth. And so if you are not able to keep up with getting enough healthy protein in every day, and taking your vitamins regularly, and coming in for regular follow-up so that we can assess that, and check blood levels to see how you're doing nutritionally, it is definitely easier to fall behind with vitamin levels and so-forth if you have an operation like the duodenal switch, or the gastric bypass, or frankly even the sleeve gastrectomy.

One of the things that we learned over the years, given the fact that we've been doing the DS operation for almost 19 years at this point, is that most of our patients actually have some sort of vitamin deficiency before they have any surgery. Close to 70% of our patients, for example, have vitamin D deficiencies. And so it's not only the operation itself, but it's the nature, and the quality of the diet that you're having, that can lead to nutritional issues.

So another question-- and this one is interesting, I hadn't thought of this. But is weight loss surgery considered to be effective? And if so, will elective surgeries get impacted with a COVID surge?

Yeah. So the word "elective" I think is a very loaded term. And when different people hear it at different times, it conveys different information. So in the setting of a pandemic, the word "elective" makes people think about things that are truly not necessary-- plastic surgery for cosmetic reasons, and that sort of thing.

But really, all elective means is that the patient and the surgeon that has had an opportunity to really sit down together, and decide when the surgery should be done based on the nature of the illness, the risk of developing further complications if the disease process is not treated, and what that time sensitivity looks like. And so we really have gone away, at the University of Chicago, from even using the term "elective."

And instead, we use this terminology-- and I know it's kind of long winded, but it conveys a lot of important information-- which is, medically necessary time sensitive surgery. And different medical problems have different levels of necessity, and different levels of time sensitivity.

And with obesity surgery, certainly, if you don't have surgery in the next day or two, it's not going to be a life threatening problem. But if you zoom back, and think about a period of six months, or a year-- particularly in the setting of COVID, where we know that the outcomes of a COVID infection can be worse with obesity, with diabetes, with high blood pressure-- then the decision-making around whether to have surgery actually starts to change.

And given the safety of the surgery, as Dr. Vignewaran pointed out, the fact that our patients don't go to the intensive care unit after surgery, and are typically discharged the first or second day after surgery, all of those are reasons to really weigh those pros and cons. And we actually have a formalized process for weighing the medical necessity, and time sensitivity of surgery, when it comes to bariatric surgery and all of our operations at the University of Chicago.

Dr. Hussain, what should a patient know before deciding on bariatric surgery?

Well in addition to everything we've discussed so far, I think the major thing to know is that bariatric surgery is a tool. It's a very powerful tool, but it's just a tool that you're going to use on your weight loss journey, and your journey to health.

I would say the majority of our patients come to us after a lifetime of struggle with weight loss. They've tried several different things. They've been successful with some things in the past, but they still feel like they need something else to lose the amount of weight they need to do, in order to live the life they want to live, and live it in a healthy way.

So because it's a tool, it's important to not forget about nutrition. When you come and meet us, you not only meet with us, the surgeons, but you also meet with our dieticians, who are extremely knowledgeable, and helpful, and are there with you to assess your nutrition knowledge and prepare you for the diet changes you're going to have to make to be successful.

You will meet with our psychology team, who's going to work with you to make sure you have the appropriate mechanisms in place to make behavioral changes, that there are no barriers in place. And if they are, we're going to help you address those things.

And weight loss surgery is also just one piece of your overall health. We are going to make sure that you're not only focused on your weight, but we want to make sure that, if you're coming to us with some of these medical conditions that will hopefully improve, that you're already getting treated for them. That they are optimized so that your surgical risk is minimal. That you're not smoking. That you're seeing that as a piece of your overall health. That you've gotten your age appropriate cancer screening.

So we view this as an important tool, an important step in your overall health journey. And I think when you view it that way, that will lead you to the best success.

John, let's play another sound bite with Brian Bates, when he talks about the reaction that he's received from people after his surgery.

I can't describe it in few words. It's just-- it's exhilarating. It is unbelievable. My husband and I, as I say, we live in London, and so we're always out socially. And we go to places-- London's one of these metropolitan areas, fashion is a big thing. Not now, in the days of coronavirus, but we would go out and stuff. And like, I'll go into a shop-- I went into a shop the other day to get a winter coat, and the guy looked at me and he says, I don't have anything in your size.

And it was-- I remember having trouble, when I was larger, trying to find things that looked good and fit well. And I said, what do you mean? He goes, well I don't have anything small enough for you now. He had to order something. And I wore a 38. Well I hadn't worn a 38 since I got my suit for when I graduated from high school. I mean, it is absolutely an amazing feeling.

That is pretty awesome. So Dr. Prachand, let's talk for a moment about the protocols that UChicago Medicine has implemented to ensure patient safety. Because in this time of COVID and coronavirus, people are a little concerned about getting out of the house, and rightfully so. But this is a very safe place to come and receive treatment.

Sure. I would say that if you were to speak to people that work here, I think that we're all proud of the response that we've had as a hospital, and as an institution, to the pandemic, and how we've been able to continue to deliver care. And when it comes to surgery, the fact that we were able to develop this prioritization process to really help us to understand which patients should continue to have surgery, and which ones it would be safer, and better to postpone until the conditions would better allow for those patients to undergo surgery.

In addition to using that prioritization process, though, we have very specific things that we have enacted here at the University of Chicago hospitals. So for any patient undergoing planned surgery, they are required to undergo preoperative COVID testing between 48 and 72 hours prior to their scheduled surgery. Because we want to make sure to avoid operating on patients who have asymptomatic COVID infections, because some of those patients can actually have worse outcomes, or complications after undergoing surgery.

We do have visitor restrictions, just to reduce the number of people coming and going. And that's not always easy for our patients and for families. But at this point in time, we have one visitor that's allowed to come to meet with patients, and to be with patients when they're here in the hospital.

And all of these things are, frankly, flexible, and change according to the severity of the infection rates in the local area and in the state. You'll see, if you come to the hospital, everybody is wearing a mask. It is a requirement, and it is something that we all adhere to. There is screening at all the entry areas for fever, and to make sure that people are wearing masks.

And in the operating room itself, one of the things that we instituted was, for operations like obesity surgery that require people to undergo general anesthesia, and to have a breathing tube placed, those times where the tube is placed and when the tube is removed, those are particularly a high-risk situation for the entire surgical team. And so we have very strict restrictions in terms of who can be in the room at that time. And we give adequate time after those particular events to make sure that any virus that's been spread into the air has the opportunity to dissipate. So this is something that we take very seriously.

It really is. And I can say, I'm on campus right now. I'm by myself in the studio. We don't have any camera operators, or anybody else in the studio. The people that kind of run the show from a technical standpoint or in an entirely separate room, walled off from me. I'm not wearing a mask, obviously, right now, but they're all masked up. And obviously, you two physicians, we've done this remotely.

So we're very serious about that, at all levels here at UChicago Medicine, and it's a very safe place to be. We are out of time. You two were fantastic. You shared a lot of really good information with our audience, so thank you very much.

And we thank you, to our viewers, for your great questions. Please remember to check out our Facebook page for our schedule of programs coming up in the future. Also, if you want more information about UChicago Medicine, take a look at our website at Uchicagomedicine.org. If you need an appointment, you can give us a call at 888-824-0200. And remember, you can schedule your video visit by going to the website.

Thanks again for being with us today, and I hope you have a great week.

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