- Hi, good afternoon, this is take two of
us being live on Facebook.
Sorry about the earlier edition, we had a little
technical difficulties with our mic,
hopefully you can hear me louder and clearer now.
So we're gonna go ahead and restart from the beginning.
Again, my names is Franz Fernandes,
I'm one of the surgeons at Baptist Hospital
that performs weight loss surgery,
and we're gonna be talking about weight loss surgery
this afternoon.
If you have any questions, please feel free to send
them in and we'll try to answer those questions
as we go along.
Little bit about myself, I've been a surgeon here
at Baptist for about 14 years.
I went to undergraduate at Georgetown University,
then went to medical school at Dukes University
for those of you who are Blue Devil fans,
go Blue Devils tonight!
And then finished up my training in surgery and
weight loss surgery in Richmond, Virginia,
at MCV, or Medical College of Virginia.
And then I came to Baptist in 2003.
I started the bariatric program here.
And I'd like to talk to you about our program,
which we kind of feel is pretty special and innovative.
We have two branches to the weight management center now.
We have both a medical and a surgical avenues.
We have doctors, and nutritionists, exercise physiologist
and psychologists that work with both sides,
and in order to offer patients the best treatments
out there for obesity.
Obesity is a disease, it is the leading cause
of preventable death in the United States,
number two is alcohol, and number three is tobacco.
So you definitely want to try to make some (mumbles)
to try and knock down obesity,
and help people with obesity have a better life.
We are an accredited center by both the societies
that govern our surgeries, the American (mumbles)
of Surgeons, and the American (mumbles) Metabolic
and Bariatric Surgery,
and also we are accredited by a number of insurances
being a preferred provider for insurances like
Blue Cross Blue Shield and United Health.
One of the things that makes our center different
than other surgical centers is that we offer a very
wide array of expertise to help people with their journey.
Surgery's not a quick fix, but it is a very powerful tool
for people to help get control of obesity
and maintain their control over obesity.
But our other members of the team, the nutritionists,
the psychologists, and the exercise physiologists
are important parts of that process to help people
get the tools, along with the surgical tool
to be able to keep this problem in check.
We do have monthly support group meetings,
as well as online support from agents after surgery.
We have two locations that we can offer patients for
the followup.
One's in Greensboro on North Elm Street,
and that's where we're coming live to you today.
The other one is in Winston Salem on Country Club Road.
Now both locations are outside of the hospital,
but the hospital that we perform all these surgeries,
there's North Carolina Baptist Hospital north of Salem,
and hopefully our patients have very limited
in contact there, do most of their care and after care
at our off site locations, which are much easier to access.
So let's talk a little bit about obesity,
and what makes a person a candidate for obesity
or weight loss surgery.
Of course, one of the main definitions is what's called
the body mass index, or the BMI,
and the easiest way to do to that is to find a BMI
calculator on the net and plug your numbers in,
your height and your weight, and it will give your number.
So anybody whose BMI is above 40 is a candidate
for weight loss surgery, or anybody who has a BMI
between 35 and 40 is also a candidate for weight
loss surgery as long as they have medical issues,
things like diabetes, sleep apnea, or arthritis
complicating their obesity.
Now there are a number other requirements like
people have had to have tried some form of diet
or exercise plan in the past, maybe even medications,
as surgery's not considered a first line treatment
for obesity.
But if people have tried those diets in the past,
and there's no other (mumbles),
things like suicide (mumbles) or active substance abuse,
then people are candidates for weight loss surgery.
Now there are four types of surgery we offer at Baptist,
the adjustable gastric band, the sleeve gastrectomy,
the Roux-en-Y gastric bypass,
and the biliary pancreatic diversion duodenal switch.
All these surgeries are performed microscopically,
meaning through a small incisions,
which helps reduce the amount of pain people
experience out of surgery, and helps to have
a shorter recovery after these surgeries.
Patients generally will spend one to two nights
after these surgeries in the hospital,
and then go home to continue their recovery there.
Now we'll talk about each of these different surgeries
briefly, I'll start with the adjustable gastric band
with the disclaimer that we have not performed
a band placement since 2013.
The reason for that is that we haven't found as good
as weight loss with that procedure as with
the other procedures, and actually have found that
more patients struggle and have problems with that
procedure longterm.
And a lot of studies from Europe and the United States,
50 to 60 percent of the bands that were placed
are having to be removed because of problems with
the band, either if the band slips, erodes into the stomach,
or people start to experience obstructive symptoms,
things like nausea, heartburn, vomiting,
even if the band's deflated.
So for that reason, the band is not really a main
state of treatment anymore in our program.
There are, maybe, certain special situations in which
the band is an appropriate treatment for weight loss,
and we can use it then.
Now as far as the other procedures, we'll start
with the sleeve gastrectomy, which is the most common
procedure we perform, it's also one of the newer weight
loss procedures in our armamentarium.
It was first described in the medical literature back in
2004, and slowly but surely, since then,
has become the most popular procedure in the United States
of America, along with our program.
Probably 2/3 of all surgeries that are done.
It's a very simple procedure,
but it's a very permanent procedure because
there's no reversing this procedure once it's done.
Physically what we do is we remove about 2/3
or 3/4 of the stomach when we perform that procedure,
and we see very good weight loss results,
very similar to the Roux-en-Y gastric bypass procedure,
which is a more complex procedure.
Patients generally will send one night in the hospital,
and be able to go home on a liquid diet the day
following the surgery, and continue the recovery at home.
Now of course it's important to kind of follow
the guidelines that our nutritionists and
exercise physiologists are gonna set,
including taking multivitamin, calcium, B12, and iron,
and progressing from your liquid diet up to a regular diet.
Now there are some risk at surgery,
though this is one of the safer procedures we have.
The biggest risk are gonna be leak and bleeding,
though those are fortunately very, very rare
and we haven't had, I personally haven't had a leak
since 2011 with this procedure,
and major bleeds requiring re-operation
are extraordinarily rare.
The more common thing we can see is an increase
in reflux symptoms after the sleeve.
10 to 20 percent of patients that have a sleeve
gastrectomy will have either worsening of their
existing reflux symptoms, or development of new
reflux symptoms after this procedure.
The majority of these patients we can manage with
just medication alone and do very well.
It's very rare, though, that we have patients that,
despite taking those antireflux medications,
which are things like Fomepizole Zantec,
they still have symptoms breakthrough that they
need further treatments.
There are some other surgical procedures we can do
to help with reflux in those cases for those patients.
Generally patients with the sleeve will lose
about 50 to 60 pounds of every 100 pounds or over
in excess body weight loss, about 50 to 60 percent.
And generally people do fairly well maintaining
that weight loss long term, though there is a chance
of weight regain with the sleeve gastrectomy,
like the other procedures.
Generally the risk with the sleeve is about
20 to 25 percent.
As far as out of work with the sleeve,
it's generally about two to three weeks,
though patients that have a fairly sedentary job,
not a real high physical strenuous job
can get back to work as early as a week after surgery.
The next procedure we'll discuss is the Roux-en-Y
gastric bypass.
This is the oldest procedure in our in our (mumbles).
This one's been around since the mid '60s,
more complicated than the sleeve,
and definitely has more risks than the sleeve,
but we do not remove any of the parts
when we do this procedure.
So this procedure is reversible.
The way we perform the procedure is we create a small
pouch out of the very top part of the stomach,
we staple off the rest of the stomach,
but we do not remove it,
and then we reroute the small intestines in order
to get a part of the small intestine up to the pouch,
so the pouch can empty, and then we connect
the small intestine back to itself.
Very effective for weight loss.
Patients will lose anywhere from 60 to 70 percent
of their excess weight, or 60 to 70 pounds
of their weight of every 100 pounds they're over
with this procedure.
And the weight loss maintenance is very similar
to the sleeve, where people will maintain most of their
weight loss off, but there is about a 20 to 25
percent chance of regain.
One of the advantages of the bypass is that it's
actually a very good reflux procedure.
So for patients that have really difficult to control
reflux, the bypass is probably the best choice.
One of the downsides of the bypass is people can
develop ulcers or stenosis at that top connection
between the pouch and the small intestine.
Things like smoking and anti-inflammatory drugs
like Ibuprofen or Alieve, Motrin, those are gonna
place patients at higher risk for developing those
complications.
So people with bad arthritis or bad back pain
who need those medications to kind of get their
day going and get through life are generally not
gonna want to have the bypass,
but you can take those medications with the sleeve.
Now the bypass is really good at helping patients
with things like diabetes to see improvement in their
diabetes both in the reduction of medications they're on,
and hopefully coming off all the medications.
In fact, one recent study showed that the effectivity
of the sleeve for diabetes is actually very close
to the bypass, so both those procedures can help
patients with that kind of problem.
Now there are risks to that surgery, it's more complicated,
so things like leaks or bleeding can certainly occur
with this surgery, right after surgery.
They're, fortunately, very rare.
The more common thing we see, particularly in
that first month is some nausea and dehydration.
It is definitely a little more difficult to eat
and hydrate after the bypass compared so with the sleeve.
So on occasion, patients do have to sometimes come
to the hospital or the clinic to receive IV fluids,
to help them kind of catch up and keep up after the surgery.
Now what they have not talked about so far is
the vitamins, but the vitamin replacements are gonna
be asked of you after both the sleeve and the bypass,
are the same.
And they include a multivitamin, calcium, B12, and iron,
and generally that is for life after these procedures.
Now if you take a multivitamin with iron,
those patients are gonna be maybe keep up with their
iron levels, and not need the iron long term
after the sleeve and the bypass,
though most patients, particular menstruating females
that are gonna need an extra iron supplement
to keep up with that.
Next procedure we'll talk about is the biliary pancreatic
diversion duodenal switch, this is the newest tool
in our sack of tools here at Baptist.
We just started performing this procedure last May,
though this procedure's been around since the late '80s,
1988 to be specific.
It is a more complex procedure than even the bypass,
with more risks than the bypass.
With this procedure, we sleeve the stomach
like we do with the sleeve, so that part is not reversible.
But then we bypass the majority of the small bowel.
So as far as helping patients with diabetes,
sleep apnea, hypertension, or even high cholesterol,
this is gonna be the most effective of all three
procedures for that.
95% of diabetics will be off their medications
and stay off their medications for the rest of their life
after this procedure.
But with that malabsorption, or that degree of
malabsorption that we see with the switch,
comes some cost, and I think that's some of the downsides
to the switch is that this is a procedure that
requires the most vitamin and mineral replacement
of all three of the surgeries we do.
So it requires a double dose of the adult multivitamin,
a much higher dose of calcium and iron,
along with B12, and then of course, because of
the malabsorption, it requires people to take Vitamin A,
E, and D, as well, the fat soluble vitamins.
The degree of malabsorption we see with this procedure
is much more than we see with the bypass.
For example, with the bypass, about 10% of the fat
a person takes in is not absorbed.
With the switch, it's more like 70%.
So that degree amount of malabsorption is what
helps this procedure be more effective against
those medical issues we talked about, like diabetes,
high cholesterol, high blood pressure,
but it also makes the most effective for weight loss.
Patients losing anywhere from 70 to 80 of every 100
pounds or over.
Generally those patients will keep that weight off.
The chance of gaining the weight back is the least
with this procedure, only about five percent.
So when you look at weight loss curves through
all three procedures, the procedure that's doing the best
at 10 to 15 years is definitely the duodenal switch.
Now unfortunately, because of the malabsorption,
there's about a one to two percent chance of protein
(mumbles) malnutrition with this procedure,
where patients may require either IV nutrition,
a feeding tube, or even another surgery to help
reduce the amount of malabsorption with this procedure.
Recovery, after the bypass and the switch
are pretty similar.
I think we still see more of the nausea dehydration
with the bypass than we do with the switch,
but I think patients experience more fatigue
and tiredness with the switch because of the rapid
weight loss that we see with these procedures.
And the weight loss is very rapid with all of
these surgeries.
Generally with the sleeve, the majority of the weight
loss happens between that first six months,
with the bypass, usually by month nine.
With the switch though, we see weight loss
into that 12 and 18 month.
All procedures generally will plateau by that
18 to 24 months after surgery.
And then that's where the work, I tell all my patients,
come in, and that's where people really have to
adapt to that new lifestyle.
And that's the key for success with all these surgeries,
is changing the way you think about food,
changing the way you eat food,
and also changing what foods you pick afterwards.
Because it's an important combination of those three
processes that's gonna help kind of keep that weight
loss off longterm.
Other issues that people talk about after these surgeries
is the excess skin, what's going to happen to all
of that extra skin I have?
And so unfortunately, it varies for person to person.
I can't give you a great answer.
Depending on the amount of weight loss you have,
more than 100 pounds or more, generally some of those
patients will choose to have skin reduction surgery.
Parts that people will operate on include the arms,
the breasts, the abdomen, the thighs.
And we've had some patients have all those done.
Generally what I recommend to all of our weight loss
surgery patients is make sure you keep up with your
protein and vitamins, exercise is an important part
of helping to tone that skin, and may help
reduce the need for skin reduction surgery down the road.
But generally what we recommend to people is
waiting about 24 months after any of these surgeries,
or until the weight's stable, before deciding to have
one of these surgeries, because the skin is an organ
and is important in the recovery,
but the body tends to skip on the skin nutrition
after these surgeries, so it suffers the most.
But it does recover some of its bounce down the road,
so it may change even after 18 to 24 months.
So I'd like to thank you for coming today.
If you have any more questions, we do have a seminar
at both locations where you can attend in person
or you come and watch our seminar online,
and thank you for your attention.