Aug. 12, 2022 - Weight Loss Surgery: Types of Surgery

For today’s Bariatric Friday, Kemal Erkan, Chairman of American Surgery Center, is accompanied by Dr. Isaias Irgau, President of Christiana Institute of Advanced Surgery (CHRIAS). Dr. Irgau specializes in bariatric surgery, also known as weight loss surgery or metabolic surgery. Bariatric surgery is aimed to promote weight reduction and a healthy metabolism. Metabolism is the process of food being broken down by the body to turn into energy. A healthy metabolism reduces the likelihood of developing certain illnesses such as type 2 diabetes, hypertension, high cholesterol, and sleep apnea. Therefore, bariatric surgery does not solely treat obesity; it also treats the related illnesses that coincide with obesity resulting in numerous health benefits. “Bariatric surgery happens to be one of the most studied areas of medicine over the years, so we have achieved standards of safety and quality, but also refinement of procedures,” Dr. Irgau states. He continues saying, “the safety of these procedures right now is actually comparable to very common procedures like gallbladder surgery, like hysterectomy, or hip replacement surgery”. Bariatric surgery refinements have led to less pain with the procedure, faster recovery, and less complications.

The discussion for today revolves around the different types of bariatric surgery and when each is needed. There are several different options, and the surgery type that is most beneficial for an individual differs from patient to patient. Often, patients visit the surgery center with an idea of the type of procedure they would prefer; however, Erkan explains that, “we want to give you the best knowledge of these procedures… we want patients to come in open-minded, so that way we can help them the best”. Dr. Irgau provides an example of a patient who thought they knew what they needed, “a patient comes in, they want the gastric bypass… but this patient is on a number of medications that require fairly predictable absorption when they are ingested… that absorption of that medication sometimes can be interfered with if a patient has a gastric bypass, which is where we have rerouted the intestine. I would counsel that patient that the sleeve gastrectomy may be a better procedure for them because with the sleeve gastrectomy we are not rerouting their intestine and, therefore, their ability to take their medications… are going to be much better”. They both encourage patients to educate themselves and attempt weight loss on their own. A patient should understand the implications and commitment bariatric surgery takes. The procedure is a tool in an individual's weight loss journey, so it is ideal for patients to have some knowledge for when they discuss with the doctor about what surgery is the right one for them.

A new cycle has begun, so the pair introduces three new patients who are undergoing the bariatric surgery journey. The hypothetical patients are used to demonstrate what a patient would experience as they go through the process of receiving bariatric surgery. The patients’ names are not real; however, the qualities and situations that they face are real patient scenarios. The first patient highlighted is Denise. Denise is 32 years old; she has an A1C of 9, a TSH of 1.5, and her hemoglobin is 9. Her body mass index (BMI) is 43, and she also has sleep apnea. Denise came to the surgery center inquiring about a lap band because she has a friend who received one and observed that it was successful for her. The lap band, gastric band, is a belt that is placed around the upper portion of the stomach. This works by restricting the amount of food a person can eat at one time. This restriction causes the individual to feel full much earlier than they normally would. The band is adjustable and can differ in size. It is adjusted through small injections through the skin and into a port device that controls the amount of fluid in the body that affects the band size. With the gastric band procedure, there is no cutting of the stomach or intestine, so this procedure is reversible. The biggest question at hand is will this be the most appropriate procedure for Denise. Dr. Irgau states, “it is clear that there is no obvious

contraindication to Denise having this procedure, but the question will be is this an optimal procedure for her. We want her to lose an adequate amount of weight and keep it off… we want to make sure that there is appropriate improvement in her blood sugar. Can the gastric band do that, yes it can, are there better procedures that could do this even more strongly.” Dr. Irgau continues to explain that gastric sleeve and gastric bypass would both be able to meet Denise’s needs. The gastric bypass would have the strongest impact on improving her blood sugar levels, but because her hemoglobin is 9, the gastric bypass could worsen anemia. Because of this, the gastric sleeve may be a better option. If Denise is set on having the gastric band, she can have the gastric band because there is no big contraindication, but the more optimal procedure might be the gastric sleeve. Dr. Irgau explains, “choosing a treatment is always a question of understanding the risks and benefits right, so if we can find that there are way more benefits to a particular option and much less risks, then the choice is more clear, and that is the discussion I would like to have with Denise about her choices.”

Erkan now introduces Patrick, a 30 year old with a BMI of 50, an A1C of 6, a TSH of 7, and his hemoglobin is 12. He is undecided on his treatment preference. A BMI of 50 is dangerously high, and Dr. Irgau tells how many illnesses related to weight will develop for Patrick by the time he is 40 years old unless the weight is addressed. His A1C suggests to him being pre-diabetic, which is a good thing that he has not developed it at this point in time; however, his TSH is high which means his thyroid is not creating the correct level of hormones. This must be addressed prior to surgery. Dr. Irgau states, “the surgery itself, the anesthesia itself could actually be dangerous if we perform it without correcting the imbalance in the thyroid.” Dr. Irgau describes in detail the monitoring plan, “we’ll follow his thyroid level, and we can do that concomitantly with the other preparation. That is the beauty of having this preparation because at the same time as we are addressing the thyroid issue, Patrick will be getting nutritional counseling, nutritional evaluation, and nutritional education to improve his eating habits as well as preparing him for bariatric surgery.” Dr. Irgau explains the procedure Patrick could possibly undergo, “we want Patrick to have a powerful procedure, but he does not need to go all the way to gastric bypass… in my experience, I found that guys do very, very well with the sleeve gastrectomy. I do think the gastric sleeve would be a good option for Patrick, and obviously I will explain to him the indications for the procedure, the risks, the potential complications… before we make a decision as to which procedure might be right.”

Karen is the next patient introduced. She is 52 years old; her BMI is 41. Karen has heartburn and diabetes; her A1C is 11, her TSH is 2, and her hemoglobin is at 12.5. She currently has her mind set on the gastric sleeve. It is important that the doctors assess her heartburn and figure out the severity. This is pertinent to note because, “not only do we want to give her a procedure that is going to be powerful enough to get her to lose weight but also powerful enough that it will protect her from acid in the stomach”. The procedure that would best aid in weight loss and protection against stomach acid is the gastric bypass. Unless there is damage to the food pipe already, there are no contraindications against the gastric sleeve. The sleeve is very helpful for patients with diabetes, and because Karen does, this could be a viable option for her. “The key and decisive factor as to whether we will go ahead with the sleeve or not will be when we do endoscopy and what we find… but on the face of it, if Karen had come to us with no choices in a neutral type of fashion, then we probably would counsel her that gastric bypass might be the better option for her,” Dr. Irgau states, “one because we want to have a big impact on her blood sugar controls, and two because obviously heartburn is an issue that we want to address as well”. Erkan explains that if she happened to be younger, they could first try a gastric sleeve for her and later on provide a gastric bypass if necessary.

Erkan points out that it is interesting that the two female patients mentioned have similar BMIs and neither have diabetes, yet they are receiving two different procedures. This proves how important it is to look at the entire scope or characteristics within a patient. Age and developed heartburn completely change the preferred type of procedure a patient should be undergoing. Between the three patients, there are no contraindications against a type of procedure, Dr. Irgau passionately says, “the only choice that I think would not be good for any one of them would be to do nothing… Unfortunately, for every thousand patients that would be eligible for surgery, only ten are coming asking for help… all of them have serious health problems related to their weight, but our job obviously is to inform them, and give them the best possible option that may be optimal for their individual situation.”

There will be about 16 sessions covering the process these patients are going through. These are detailed and informative discussions, but Dr. Irgau makes clear, “the best time for us to actually give and provide treatment would be when we have an individual discussion where not only we talk about what is the best procedure, but we will talk about the potential complications of surgery… look at the benefits and the risks of the treatment for them to be comfortable to choose the treatment that is appropriate for them.”