BN Multi's Clinical nutritionist Jacqui Lewis talks with Dr Arun Dhir, a leading bariatric surgeon for 25 years. Here they explore the differences between Gastric Sleeve, RNY Bypass and the application of each surgery, as well as outcomes that can be expected and how to determine the best procedure for each individual's situation.
Welcome to the Australian Weight Loss Surgery podcast, where every two weeks we explore all the aspects of the weight loss surgery journey. We’ll hear from a range of experts, including bariatric surgeons, psychologists, patients and dieticians cheering up to date informative advice to help fast track your long term weight loss success.
Jacqui: Here I am in the office of Arun Dhir at Melbourne Gastro Surgery in Melbourne, I’m visiting today to discuss and explore bariatric surgery and find out a little bit more about the different types of surgery and Arun’s experience with the surgeries as well. So without further ado, I’ll introduce Dr Arun Dhir . Arun, can you tell us a little bit about yourself?
Arun Dhir:Thanks, Jacqui. Thanks for the opportunity and lovely to talk to you. Well, look, it’s been a journey of over two and a half decades now. Seems like a long time ago. But I think when I was in med school, there was little that was offered in terms of a, you know, a solution to tackle obesity because it wasn’t so much of an issue at that point in time. However, we have seen that as technology has advanced and our society has changed as a as a whole, that the advent of more convenient foods and lifestyle changes, we have been seeing this scourge of obesity not only come up in developed nations, but it’s the developing nations which are facing the brunt significantly. Now, I often say this to patients that, yes, surgery is a powerful tool, but surgery does not have the ability to fix the world’s obesity problem. Exactly. So we need to acknowledge that. But then we need to use the lessons learned and try and get out of the situation that we are in currently. And hence, my message is that we have to have an integrative and holistic approach to managing obesity rather than just one tool. And that fixes everything.
Jacqui: Exactly. So we’ll discuss that in later episodes as well, which will be very interesting. Thanks, Arun. So firstly, I just wondered if you can tell us a little bit about the different surgeries. What types of surgeries are offered for weight loss surgery patients?
Arun Dhir: In the current days, context surgery, of course, as we know, has evolved as we have understood what works, what doesn’t work. And new new insights have been gained over the period of a few decades since bariatric surgery has been done. And I’m talking about surgery, which started in the 1950s to 60s with bypasses, which were like fairly morbid operations to now we have understood that procedures like artificial prosthetics such as lab, and they may be working only for a very select population and they are high maintenance and they create a unique set of issues. So that is something that has come out of the understanding of how this works over the course of the last few decades. So currently, what I offer in my practice as the number one procedure, which most of the people would prefer, is a gastric sleeve, then we offer the two different kinds of gastric bypasses, the Roux En Y gastric bypass and the one anastomosis or mini gastric bypass. There are newer procedures which are on the horizon, such as the Sadi procedure, then the endoscopic sleeve gastroplasty or sleeve gastrectomy. Some people like to call it, but it’s not a gastrectomy. It is actually suturing or stitching the stomach into a long to pass the endoscope in. So there are all these new procedures, but I think they are still experimental. I don’t think we have that degree of confidence that we can offer it with a good, safe, long term safety profile.
Jacqui: How long have these surgeries been around?
Arun Dhir: for the new ones, the SADI? Well, they are all in the five or under five year old. So I don’t know what happens at the 10 year mark. And again, each operation has got a unique set of advantages and disadvantages. And I think that my understanding over the years has come to this conclusion that, you do a procedure that you understand well that you can guide your patients through well, to understand what are the pros and cons of that procedure so that you use it to your best advantage. And that’s why we feel comfortable with the ones that we offer.
Arun Dhir:: And we’re seeing an uprising in the bypass in some situations.
Jacqui:Do you see a different result for patients as far as weight loss goes, maybe longevity of their weight loss? Is there a difference between the sleeve gastrectomy and the bypass as far as the results?
Arun Dhir:: Absolutely. And I think what we need to understand Jacqui is and this is being recognised internationally already in the sense that, the organisations, the peak bodies that are,, bodies that lay out guidelines for weight loss surgery have restructured. I didn’t reframe the guidelines to address metabolic surgery, so metabolic surgery is now considered to be aimed for people who have metabolic syndrome, such as diabetes, which is a complication of obesity. So their BMI may not be that high, but they may still have issues like truncal obesity, fatty liver, high lipid levels, cholesterol levels and high levels of insulin, which all represent insulin resistance or metabolic syndrome, which is something that is the number one risk factor to developing strokes, cardiovascular conditions and all of that. So when it comes to an answer to your question, when it comes to the difference between the sleeve and the bypasses, bypasses clearly have a much powerful metabolic effect. So if I’m dealing with someone who’s got diabetes, who’s got severe sleep apnea, he’s got a fatty liver. My inclination would be to consider a bypass if it is the safest procedure for that individual.
Jacqui: And from a nutritional perspective, what are the implications when you compare the two surgeries?
Arun Dhir: Great question, and it’s very relevant because the thing is that, you often get younger females on one spectrum, young mums who have gained so much weight and their their BMI is in the 50s and they are struggling to get off the baby weight because they have had a few pregnancies. And on the other extreme, you have slightly older men and women who have developed that truncal obesity, which has led to issues around sleep apnea and things like that. So I think what I see in answer to your question is that the unique challenge in the younger women is sometimes nutritional deficiencies which can come up, which is iron and vitamin D that you see quite often. Protein also is something that is pertinent and it’s very important to keep a track of the albumin levels in the regular blood tests. . And that is something that we used to see when we were bypassing long segments of small bowel, which we don’t do anymore. At least there is an international consensus that over two metres of small bowel, will lead to significant degrees of malabsorption and albumin levels drop and all those side effects start to come in. So fortunately, there is a better understanding of that once again, and we don’t see that as often. But it is rare.You know, and once again, there are other aspects of each operation, for example, ruined by gastric bypass. People developed ulcers. There’s a risk of internal herniation which are unique to the Roux En Y gastric bypass. And the one anastomosis or the mini gastric bypass can lead to some bile reflux. So if an individual already has reflux and they’ve got metabolic syndrome, then I tend to shy away from the mini bypass and offer the Roux en Y gastric bypass. When there’s a selection algorithm that we go through with the patients based on their age, their risk profile, their BMI and their other metabolic risk factors in order to come at what is the safest option for them.
Jacqui : So safety first, of course.
Arun Dhir: : Absolutely. Safety and then matching it to the profile of the individual. That’s the key thing.
Jacqui: Start with the sleeve gastrectomy. Can you tell us a little bit about the way the anatomy is modified in that operation?
Arun Dhir:: So basically the sleeve gastrectomy, as the name suggests, is that sleeve meaning you make a tube off the stomach. Gastric means you remove a portion of the stomach. So essentially what we are doing is that the basis of the operation is that the gastric fundus produces ghrelin, which is the hunger hormone. And when you remove the fundus, meaning the part of the stomach, which is the bag or the balloon part of the stomach, once that is removed, the individual’s hunger drops significantly.
This has been proven by scientific studies and based proof that up to three years there is a significant drop that is maintained in the ghrelin levels. Now, mind you, ghrelin is a hormone that we have understood and discovered to be associated with our hunger mechanisms. But that’s not the only hormone. There are several other hormones, which probably we haven’t discovered as yet because it’s a very complicated mechanism. The appetite and hunger control are very complex. So that operation, basically the beauty of the operation is that it allows the food to go around the food by the stomach and the small part very naturally. The only difference or the advantage being that the portion control is a significant benefit that individuals get. So people who may be eating healthy, but as. With portion control, it’s a great operation, BMI, less than forty five, if that’s what the individual profiles are. Again, I think sleeve is a good option because it allows the food to go down the natural passage, reducing the risk of developing nutritional deficiencies. So that’s a great thing.
Jacqui: And as far as the bypass goes, one of the changes.
Arun Dhir: : So with the bypass, as the name suggests, we bypass a portion of the small bowel, which is the upper small bowel and in the wrong way we make two joints, so a small part of stomach and then we attach a segment of the small ball to which there are two limbs, basically the biliary limb and the elementary limb. Most of the surgeons would make an elementary limb off about a meter or so, which is about 100, two hundred and 110 centimeters. And most of the surgeons would have them off about seventy five centimeters. Sixty five to seventy. Now, there’s no written rules about it, but most of the people, most of the surgeons would agree on that. Having said that, the one anastomosis bypass if the BMI of the individual is 50 or less than we go for a bypass of about 150 centimeters. But it’s only one
joint when the when you’re doing that with BMI.
Jacqui What is that mechanism that you’re utilizing there?
Arun Dhir:: So great question. And there are two things that both these operations do. Number one, it changes the gut hormones. So that allows the recalibration or resetting of the metabolic or the thermogenic point, which means, you know, like your body has got a set resting metabolic rate. When a bypass operation is undertaken, it causes change in the gut brain communication and that resets the metabolism of the individual. So hunger goes down and metabolism goes up. This is a very interesting thing. Absolutely. So it is not just a mechanical affect you because the first bariatric operation just out of interest was rewiring the jaws of the individual. You know, which is funny because, again, it shows how much we understood obesity, but that was clearly a failure. It never worked. So now we have understood that it is the nove and the neuronal and the hormonal signals that go from the gut to the brain that influence our hunger and appetite mechanisms.
Jacqui: So I guess the umbrella of it is you’re altering the hormonal responses, changing that gut brain conversation in ways as well as limiting the portions in both of the surgeries.
Arun Dhir: : Absolutely. And there is enough scientific evidence to prove that there is a gut brain axis. There is a two way communication happening, not just one. We’re going from the gut to the brain or the brain to the gut only. And the second important aspect jackin further to what I just mentioned is the change in the individual’s gut microbiome, which is the bacteria that live in your gut. They’re unique to you and they are playing a key role in determining your metabolism. So this is the third party which comes into the mix. And we are actually currently doing a study jointly with La Trobe University, which is purely accessing and analyzing jointly with the microbiology department. They’re analyzing the changes in the gut microbiome of individuals who have had many gastric bypass surgery. And so that is something that is something that we are really excited about. And we’ll be presenting it at a conference later in theyear.
Look, I don’t claim myself as an expert because honestly, the fact is the more you learn about it, the more you realize that you don’t know enough to know. There is so much that is unknown that you know. And I think that is the reality that every new discovery opens our eyes to so much that we don’t know. And that’s the beauty of it as well. So, you know, so I think in answer to your question, I think the gut plays a huge role in our not only management of weight, but our overall health, our vitality, our immune system, which is seated in your gut. So your gut is the seat of your immune system. And then we are feeding a diet which is of processed foods, which is full of preservatives, chemicals, antibiotics, as is there in lots of meat products and all of that and hormones as well. It actually disrupts our gut microbiome. And when the gut microbiome is disturbed, it sets a degree of inflammation in the gut, which leads to a broken or an open. Barrier between the looming of the gut and the actual blood supply, so all these undigested particles, they start to enter into the bloodstream, creating a state called these and cut inflammation. This concept is not acceptable by every gastroenterologist, every physician, because clearly there will be people who will challenge your views. But I guess my only question to people is that our current model of treating patients with only bills and procedures is not work. Exactly. If you see the overall incidence and you look at the medical charts actually and they present numbers every quarter, incidents of obesity, cancers, diabetes and cardiovascular problems are only going up.
Jacqui: So we are missing the point that even with the right of these procedures is exposure and all these other public health programs that are targeted towards diabetes
Arun Dhir: Correct.. But we’re still seeing that increment. Absolutely. I mean, you look around in the supermarket and you walk down the street and we’ve just got this marketing and we’ve got so many external impacts that we just have to be so vigilant. And I think I don’t think we were brought up that way today.And I think my biggest concern is that it is already at the point where it’s unsustainable, like Australia takes pride. And I worked in the system for over 20 years now. And I can say hand on my heart, we’ve got a beautiful ethical medical system. It is really well and we provide. And I compare this with other countries. You know, it’s an amazing system, but it is reaching a point that it’s unsustainable. We cannot sustain this degree of medical expenditure anymore. And I think we all need to wake up and start taking charge. I’m not saying that you shouldn’t go to hospitals if you have a problem. I’m saying that you can do things right now. I often see your kitchen can change your health destiny. Oh, absolutely. Just your kitchen. So what you’re putting in your mouth, the kind of processed foods, the kind of beer you’re buying, what stuff from that alone has the ability to start to recalibrate your metabolism in a way that you start going from a catabolic, which is which creates more inflammation of pro inflammatory to an anti inflammatory. And this is just one example of it.
Jacqui Absolutely. Thank you. And we’ll just touch on your book very briefly. Can you tell us a little bit about the origin of that one? Yeah.
Arun Dhir: So my book wasHappy Gut Healthy Weight , I launched it in December2018 And I think it was really an instrument of providing some genuine information without an intention to try and sell something to my patients who would come and see me, because I have always believed in a very holistic and integrated approach to managing obesity. And I tell them that I’m not in the business of doing surgery and then more surgery and then more surgery because we need to fix the root of the problem. And we can only get to that if we understand where it is stemming from. And that’s where it was a labor of love and service to the community and people who put their trust in me so that I could, instead of trying to repeat it every time I said, this is a book that I’ve written and I’ve gifted it to a lot of my patients as well. But the idea is that it is something that gives them an overview as to how their stress, how their diet, which is the toxic ingredients in their food, how the gut microbiome which alters sets up a state of inflammation in the body and poor gut health, which is all linked. So it goes into the gut brain axis. And then there are certain daily practices. I’m not talking about any supplements or anything. We’re trying to sell anything in the book. But there are daily practices that an individual can start incorporating to to start seeing the beneficial effects of this. Yeah, that’s my message
from a health perspective.
Jacqui Absolutely. Which is bringing around that multifaceted approach to change absolu education. Yes, the surgery is a tool and it is obviously research and it’s showing that hormonal and also mechanical changes. But if it’s not supported with lifestyle, what are your thoughts on that?
Arun Dhir: Absolutely.
And I think my message in that book and through that book really is that, yes, there is a role for antibiotics. There is a role for pills, there is a role for medications, absolutely, you know, they have been blessings of modern medicine to humanity lengthening our lifespan. But I guess the bigger question is it has not served us well in improving our health because of the convenience and the lifestyle changes that we have embraced accidentally, which is not intentionally. We’ve got a television game. We started eating on the couch and suddenly we found that, people are becoming couch potatoes. So it’s just a small example. But the point is that mindful eating, which is what I talk about in the book, is really not eating in front of the screen and connecting with your food to a small example. But that itself allows you to appreciate the taste of what you’re eating, but also realizing when you’re full, you’ve got to say thank you and then you push it away. Whereas while you’re eating in front of a screen up so disconnected, you just don’t know when you’ve finished the whole pizza and it’s gone and you’re still hungry because you haven’t recognized it actually in the moment.
jacqui: I’ve also read if you’re happy or your content and your eating, you also draw more nutrition from that food and that comes down to the relaxation state.
Arun Dhir: Correct. And what you’re talking about is the relaxation response, basically, which is the entire opposite of a stress response, because when you’re eating in a mode of stress, it’s like the body thinks you’re on a diet that is tolerable. There is famine and it tries to conserve every bit of calories that you’re taking. And you just wonder if you’re eating healthy. But you still gaining weight
Stress management is a big part of weight management, I say, because if you’re stressed out and if you’re not sleeping adequately, you cannot expect to lose weight. Exactly. So these are all different strategies that we talk about in the book and in the workbook and the journal and all of that.
Jacqui What a great combination. Oh, thank you. Well, thank you so much for your time today. We’ll be speaking with you again in the future. Absolute guarantee. Thanks very much. Thank you.
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