Top Bariatric Surgery Questions

Is metabolic and bariatric surgery right for you? On this episode of Butts & Guts, Cleveland Clinic general surgeon, Dr. Rickesha Wilson, discusses current surgical options for health and weight improvement. Listen in to learn what to expect before, during and after these weightless procedures.

Transcript

Scott Steele:                      Butts & Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end. Hi again everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the president of Main Campus here at Cleveland Clinic in beautiful Cleveland, Ohio. And today I'm very pleased to have one of our very own, Dr. Rickesha Wilson, who is a bariatric and general surgeon and an assistant professor of surgery at Cleveland Clinic Learner College of Medicine here at the Cleveland Clinic. Rickesha, welcome to Butts & Guts.

Rickesha Wilson:              Thank you so much for having me. I'm so glad to be here.

Scott Steele:                      Today, obviously we're going to talk a little bit about some bariatric surgery FAQs, but before we dive into that, we always like to start out here on Butts & Guts with giving us a little bit about your background, so where are you from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Rickesha Wilson:              Well, I was born and raised in Texas, so southern girl for sure, Fort Worth, Texas, where I was born and raised, family still out there. I went to Baylor for college and then Texas A&M for Medical School. Then decided I wanted to venture out and see other parts of the world because we think Texas is its own country in some ways, so a mentor of mine connected me at the University of Connecticut. That's where I did my general surgery residency. And then I interviewed, was interested in bariatrics and minimally invasive surgery and met the team here at Cleveland Clinic and decided to match here for a year of research with Dr. Ali Aminian, and then did my fellowship here. I wanted to get back to Texas or so I thought, but I was looking for jobs during COVID and so a opportunity ended up opening up here at the clinic to stay. And I thought that this was a great option and the culture's wonderful, so I decided to stay on the staff and got some better winter gear and I've been loving Cleveland ever since.

Scott Steele:                      That's fantastic. And sometimes good things come out of the pandemic. We're glad you're here. Today we're going to talk a little bit about bariatric surgery, and there's a lot going on in the field of weight loss and metabolic health and all of that stuff. And we want to answer some of the most common questions that patients have when considering whether the surgical aspect of it is the right option for them. Let's start really high level, so why should someone seek metabolic surgery?

Rickesha Wilson:              I'm glad you also said metabolic and not just bariatric, but someone should seek metabolic surgery or bariatric surgery if they want to be healthier and if they are having a hard time, first off with their weight, if their weight is high, and also if they have medical conditions that could be related to their high weight. Obesity is characterized based on your weight and your height or your body mass index, so if your body mass index or BMI is 35 or higher, you might consider seeking weight loss. And so of course for surgery, you might also seek surgical care if you also have diabetes, high blood pressure, obstructive sleep apnea, maybe a hernia, or even if you're seeking other surgeries where you might not be able to qualify for surgery until you lose a certain amount of weight, surgery is for all those individuals in that category.

Scott Steele:                      It seems like there's so much talk about all the different weight loss options. And so who is a good candidate for surgery?

Rickesha Wilson:              Well, you have to meet a certain weight criteria, so really if your body mass index is 30 or higher, you should at least seek counsel. Your primary care provider is a good place to start to say, "Hey, do you think I might qualify or I'm serious about improving my health." But individuals at a certain weight BMI of 30 or higher. And those who have medical conditions that they're having a hard time controlling, or if you want to get off of some of those medications for your high blood pressure or for your diabetes and for your high cholesterol. Individuals with higher weights who would like to lose weight, and those who would like to be healthier to not only help with their current medical conditions, but if you are seeking to avoid certain medical conditions down the road, maybe diabetes or heart disease runs in your family, you're at higher risk for a lot of those diseases related to obesity. And many people don't know that, so anyone curious should at least start asking the question, how can I get healthier? How can I lose weight? What are my options?

Scott Steele:                      I'm a little bit of a surgical nerd as well as a history buff. And looking back, everything from the Scopinaro's procedure to the vertical band of gastroplasty to the gastric band, to resectional gastric bypass and duodenal switch and everything, there's a lot of surgeries that have come and gone and some that have stayed. What type of surgeries at present and now as we sit here are available and which one do you recommend or how do you tailor that, if you will, to the individual patient in front of you?

Rickesha Wilson:              Great question. And the field of metabolic and bariatric surgery has grown and evolved so much. And so a lot of the procedures that you mentioned have been improved upon as we've done research or learned from patient cases and experiences. We want to help individuals lose weight, but we don't want them malnourished. And so about over 90% of the cases that are done today all over the country will be the sleeve gastrectomy and the Roux-en-Y gastric bypass. Those are the two most common procedures. And those two procedures would probably serve most folks very well. And the sleeve is the most common, and it's our simplest procedure where we remove about 80% of the stomach through small incisions, take it out the body, and it's usually a one-night stay in the hospital. The sleeve makes the stomach smaller, the gastric bypass, we don't remove the stomach, but we exclude most of it.

                                             We make a small pouch from the top of that stomach, and then we involve the small intestine and connect it to that small pouch in order to not only restrict your eating, but alter the way you absorb your nutrition. And so your gastric bypass and sleeve are the most common. There are some others for higher weights, the duodenal switch in the SADI that are options that you can discuss with providers also. But with the sleeve and gastric bypass, depending on your weight loss goals, if you want to lose some weight, you don't have to lose a ton. Or let's say you've had a lot of abdominal surgeries or let's say that you are anticipating another procedure and just need to get to your goal. With a sleeve, you'll lose about 25 to 30% of your body weight, the gastric bypass, you'll lose a bit more. And sometimes, depending on those who have diabetes, that might be a preferred procedure, so for each individual, we really take a deep dive into their history and see what their needs are and base our procedure choice on that.

Scott Steele:                      You touched a little bit about this previously, but a lot of these procedures talk about either exclusion of a part of the stomach or removal of the stomach, and let's just put this to rest now. I hear people say all the time, well, people just need to eat less than these gastric procedures. That's living proof that it is, but it's much more than that, isn't it?

Rickesha Wilson:              Absolutely.

Scott Steele:                      There's so much going on. On a very high level. Can you talk about some of the other things that are going on? You mentioned a little bit of it in terms of the ability to be able to absorb nutrition, but there's some hormonal instances and other things. Can you talk about that?

Rickesha Wilson:              Absolutely. And the biggest hurdle that we run into when we are counseling patients is we're trying to break the stigma of people even showing up for bariatric surgery, so you're exactly right. Our weight is not just, oh, you need to eat less and work out more. We have plenty of patients who are doing all the things that they need to do. Their lifestyle changes have changed, they are exercising, running, and they're still not losing weight, so genetics plays a big role. Medical conditions and hormone changes based on the medications you might take. After having kids your body changes as well for women, so there are so many factors other than just your exercise and eating that play a factor into our body weight. And so a lot of people get discouraged because they're trying their best to diet and exercise, but it is hard to beat biology, and your body has a set point where it wants to be at.

                                             Sometimes your body will say, we're at 290 pounds and that's where we want to stay, so the more you work out, the hungrier you might get, and that's because of the hormonal changes. And so we've found that with bariatric surgery or metabolic surgery, the gut hormones that talk to the brain and back and forth, those are the things that actually get altered, and they can help reset that set point to a lower weight for our patients. But we always emphasize surgery is just a tool and obesity is a chronic disease, and so you have to monitor these things even after surgery.

Scott Steele:                      Let's just say that we're going to go ahead and do surgery now. When somebody's preparing for that surgery whatever it is, is there a specific diet or exercise plan that needs to be followed? Sometimes I hear patients say, "I'd love to be able to exercise or anything, but my weight has hurt my knees. I can't really exercise. I don't have access to a pool or anything." What about this?

Rickesha Wilson:              Anyone who's considering surgery, when you enroll in a program, and most of the time you'll have to enroll in some sort of bariatric program where you're going to see several types of providers from not just a surgeon, but a nutritionist, a psychologist, an obesity medicine specialist. All of these people are there to educate you, not just evaluate you, but educate you about the process, about what it's going to take for you to be successful. And you're right, not everybody's able to exercise and do all the things because of severe joint arthritis. We have some people who need to get listed for a heart transplant, and so they can't exert themselves, so we certainly evaluate and counsel patients.

                                             Now, some people think that, oh, I have to lose a certain amount of weight before I'm approved. No, not necessarily. Now, we do want to know that you can make some of the changes necessary based on your medical conditions that are safe for you. We want to know that you can make those changes so that you'll be successful after, but you don't need to lose a certain amount of weight. You will need to follow a vitamin regimen every day and just a couple of weeks before surgery a lot of programs might put you on a liquid diet just to shrink the liver a bit and start a little bit of weight loss. But other than that, you just need to prove that you can make responsible changes for success afterwards.

Scott Steele:                      You mentioned some of the appointments that need to be completed before surgery. Are there any other specific tests that have to be done?

Rickesha Wilson:              Yeah, absolutely. Some tests are routine, really just to check your physical health and make sure you're safe for surgery. A basic chest X-ray, an EKG or electrocardiogram. We often do an ultrasound of the liver and the gallbladder to see if there are any stones. Fatty liver disease can be measured with those. Those are some of the basic tests, including basic blood work that we would need just to evaluate your overall health. But some individuals might require advanced testing, maybe to test for sleep apnea if we are suspicious that you might have it. Many people come to us with undiagnosed medical conditions, so based on your medical conditions, we might need to look at your heart a little bit more, your lungs and your breathing more, evaluate for reflux, heart disease, hernias, things like that.

Scott Steele:                      I know the vast majority of these procedures can be done through, depending on the patient's obviously history and how the case goes, through minimally invasive procedures. Can you talk a little bit about recovery? What does that process look like?

Rickesha Wilson:              Yeah, absolutely. We're happy to say that bariatric surgery is safe and as safe as a lot of the common procedures that others may get, such as an orthopedic procedure, like a knee arthroscopy or a gallbladder removal or a partial hysterectomy. And so the expectation is that you'll stay in the hospital usually one night on average, maybe a day more if you have higher medical needs. But usually we say recovery is within two weeks. We have people going back to work, because surgery is done with small incisions, they're back to work within one to two weeks. But if people need more time off or want to recover and adjust to the new diet, then you can certainly have more time off. But within two weeks, even in the hospital, you're already walking around drinking liquids the night of, and so recovery is expedited nowadays.

Scott Steele:                      You teased this a little bit earlier with talking about diabetes, but how else can your health change after surgery?

Rickesha Wilson:              Many studies have looked at the outcomes of a lot of medical conditions after significant weight loss. People are pleased to find out that their high blood pressure has improved. They might need less medications or none. Diabetes, like we mentioned, some of our patients can come off of their CPAP machines because their sleep apnea is so much improved. The amount of weight you lose or a dose dependent response is what we've been seeing for the improvement of other medical conditions. And so I think people who lose significant weight and because they're using their tool and doing the things that they need to do to be healthy and maintain their health, I think they can see a drastic change in their other medical conditions and the prevention of a lot of medical conditions related to obesity.

Scott Steele:                      As far as lifestyle changes after surgery, how different does life look for the patient post-surgery?

Rickesha Wilson:              It's different in that your relationship with food will change fairly drastically. We eat for pleasure. Eating is fun. It's something that we do a lot of for different reasons on different occasions. And so the biggest thing I think is that you'll be very restricted, so the normal plate you used to eat, you'll be able to eat maybe a fourth to a third of that at a time. And so there's a new normal. Instead of eating one or two big meals a day, you'll find yourself eating five to six smaller meals throughout your day. And so you are restricted first. Second, you have daily vitamins that are really important.

                                             Every patient who is considering surgery and who has undergone surgery knows that you'll have daily vitamins that you'll need to take to supplement your nutrition to make sure you're getting the minerals and vitamins that you need. And then otherwise, before surgery, you may have to make hard choices to avoid certain things. Sometimes you can't even tolerate some of your favorite things like ice cream or cake or something really sweet or sugary. Many patients find out that it actually makes them sick. And so there's, I think, a drastic change in what you can eat and how much of it.

Scott Steele:                      You've teased that there are some patients that may be back to work as little as a few weeks, but what other kind of follow-up care is necessary after bariatric surgery?

Rickesha Wilson:              After surgery, at least in our program at Cleveland Clinic for sure, there's a lot of opportunity to continue your follow-up. We don't just do surgery and check on you one time and then we're done with you. At our program, within the first month, you're meeting again twice with the surgeon for a check-in at two weeks and at one month, you're meeting with our psychologists, our nutritionists, and we have ongoing monthly support groups as well. You'll have a three-month check-in and then an annual check-in with blood work also to check your vitamins. But there's extensive follow up. Now, of course, some people get lost to follow up just because they're feeling good and moving on with their lives. But we offer a lot of support, especially here at the clinic in our program, for people to follow up to really ensure their success and maintain the health changes that they're seeing.

Scott Steele:                      I know despite whatever method is out there to lose weight, there's always that fear of regaining weight. What are the chances of regaining weight after the surgery?

Rickesha Wilson:              It depends on each individual, but yes, you certainly can regain weight, especially number one, if you go back to maybe old habits, no one can beat liquid sugar. We don't have a cure for that. I would say if I put a number on it, 10 to 15% can regain some weight, and now the majority of individuals within the first year, 12 to 18 months, you'll get down to your lowest weight that you'll likely see, and then you might bump up just a little bit after that and then maintain a much lower weight than you had before surgery. But weight regain depends on your lifestyle habits and changes and your biology.

                                             We have support groups and ongoing support for patients for this reason, because some of those cravings can come back. It's not a silver bullet or there's no magic to it. And so having good healthy habits beforehand about what you eat, about your discipline, about exercising is really crucial to success after surgery because some of those cravings can come back, and of course you can make appointments and meet with providers to talk about some of that stuff. But weight regain is a real thing. And outside of lifestyle changes, there are medications that can help curb your appetite. Maybe you're five or 10 years out and you're needing some extra support. And as a last resort, there are surgeries as well.

Scott Steele:                      Interesting. What is on the horizon as far as innovations in bariatric surgery and recovery?

Rickesha Wilson:              In terms of surgeries that are on the horizon, we are trying to modify and improve upon the surgeries that we already have. Back in the early days, we used to bypass too much intestine, back in the earlier days when we had some of the other procedures, so we've learned to measure a lot of the intestine before we bypass to find out the optimal length. And we're doing a study here at Cleveland Clinic trying to measure individual's intestines, and we're bypassing a certain percentage of the intestine and not just a certain number because every individual is different. We have endoscopic interventions to try to improve... Maybe endoscopic interventions, so people who may not be candidates for surgery might still have an option for weight loss. And of course, in terms of recovery, I think our recovery right now is excellent, but I think a lot of the country and programs are trying to move toward even getting patients home the same day.

Scott Steele:                      That is so interesting. Now it's time for our quick hitters, a chance to get to know our guests a little bit better. First of all, what was your first car?

Rickesha Wilson:              It was a green 1995 Honda Accord.

Scott Steele:                      Fantastic.

Rickesha Wilson:              Stick shift, by the way.

Scott Steele:                      5-speed?

Rickesha Wilson:              Oh, yeah.

Scott Steele:                      What was your favorite trip?

Rickesha Wilson:              Ooh, favorite trip? Probably one of the early ones to London. I was in college. I visited my sister abroad when she was in law school.

Scott Steele:                      Fantastic. What's your favorite dessert?

Rickesha Wilson:              Favorite dessert? I live right near a Heinen's. It's their carrot cake.

Scott Steele:                      Nice. Finally, what is a hidden talent that you might have?

Rickesha Wilson:              Hidden talent. I would say probably singing. I grew up in the choir, my shower knows and my car, but most people don't know I can hold a tune.

Scott Steele:                      Give us a final take home message to our listeners regarding bariatric surgery.

Rickesha Wilson:              My take home message is that if you're curious about bariatric and metabolic surgery, you are struggling with weight loss and struggling with your help, there are solutions out there for you. And I encourage you to go to Cleveland Clinic's website for bariatric surgery to take the first step, watch our seminar and sign up, ask questions. Or if you're not here locally, ask your primary care provider more questions about how you can sign up. And just know that bariatric surgery is one of the most effective options compared to lifestyle changes and medications for significant weight loss. And you're not just treating your weight, you're improving your health overall, and you're preventing many health conditions that are coming down the pipeline for your life if you don't treat your obesity. And so I would say that people should think about their health now and what they want their quality of life to be later. And I think bariatric surgery is a great option. And people don't know, most major insurance carriers will cover bariatric surgery before they'll even cover some of these newer medications.

Scott Steele:                      That's fantastic advice. And so the first step in your weight loss surgery journey is participating in our free seminar to learn about the surgical options, our patient navigators, as well as what to expect before, during, and after surgery. To watch our seminar, please visit clevelandclinic.org/bariatrics. That's clevelandclinic.org/B-A-R-I-A-T-R-I-C-S. Dr. Wilson, thanks so much for joining us on Butts & Guts.

Rickesha Wilson:              Thank you. My pleasure.

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