What is Bariatric Surgery?

Who qualifies for WLS and what type of surgery might be best for me?

Today we will talk with Dr Arun Dhir at Melbourne gastro surgery in Melbourne to discuss and explore bariatric surgery and find out a little bit more about the different types of surgery and Aaron’s experience with the surgeries.

Well, 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 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 as a whole, but the advent of more convenient foods and lifestyle changes.,we have been seeing this, you know, 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 , surgery is a powerful tool. But it does not have the ability to fix the world’s obesity problem. 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 that fixes everything.

Can you tell us a little bit about the different surgeries what types of surgery on offer for a weight loss surgery patient?
Bariatric or Weight LOss Surgery of course has evolved as we have understood what works, what doesn’t work and new new insights have been gained over the period of the few decades since Bariatric surgery has been done. I refer to surgery which started in the 1950s to 60s with bypasses, which were like fairly morbid operations compared to now, we understood that procedures like artificial prosthetics such as lab bands, 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 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 Gatric Sleeve. Then we offer the two different kinds of gastric bypass is the Rouyen Y gastric bypass. And the one anastomosis or mini gastric bypass. There are newer procedures which are in the horizon such as the SADI procedure than the endoscopic sleeve, gastro plasti or sleeve gastrectomy as some people like to call it but it’s not a gastrectomy. It is actually suturing or stitching the stomach into a long to passing the endoscope in. So there are all these newer 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.

How long have these Weight Loss Surgeries or Bariatric surgeries been been around for?
the new ones the SADI etc, well, they’re all in in the five or under five year realm. So I don’t know what happens at the 10 year mark, you know, and again, they each each other 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. currently.

Do you see 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?
Absolutely. And I think what we need to understand is and this is being recognized internationally already in the sense that you know, the organization’s the big bodies that are bodies that layout guidelines for weight loss surgery have restructured and reframe their guidelines to address metabolic surgery. So metabolic surgery is now considered to be aimed for people who have got metabolic syndrome such as diabetes, which is complications of obesity. So their BMI may not be that high, but they may still have issues like abdominal obesity, fatty liver, higher lipid levels, cholesterol levels and high levels of insulin, which all represent insulin resistance or a metabolic syndrome., which is something that is the number one risk factor to developing strokes, cardiovascular conditions and what we term to be “co morbidities” . So when it comes to in answer to your question when it comes to 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, Sleep Apnea and a fatty liver. My inclination would be to consider a bypass if it is safest procedure for that individual. Right.

And from a nutritional perspective, what are the implications when you compare the two surgeries regulation and the bypass?
And it’s very relevant because the thing is that, you often get younger females on one spectrum, young moms who have gained so much weight and they are their BMI is in 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 other health related issues due to their excess weight. So I think what I say in answer to your question is the unique challenge in younger women is sometimes nutritional deficiencies which can come up which is iron and vitamin D that we see quite often. Protein also is something that is pertinent. And it’s very important to keep a track of the albumin. And but that is something that we used to see, when we were bypassing long segments of small bowel, which we don’t do anymore. Well, at least, you know, there is an international consensus that over two meters 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 there

And it’s time will tell isn’t it?
Well, that’s true, and once again, there are other aspects of each operation for example, rouyen Y gastric bypass, , people develop stomach ulcers, there is a risk of internal herniation which are unique to the rouyen Y gastric bypass and one and anastomosis or the mini gastric bypass can lead to some bile reflux. So if an individual already has got reflux, and they’ve got metabolic syndrome, then I tend to shy away from the mini bypass and be offered the Rouyen Y gastric bypass. And 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 to decide what is the safest option for them. So that so Safety First of all, absolutely safety and then matching it to the profile of the individual. That’s the key thing.

With the the sleeve gastrectomy. Can you tell us a little bit about the way the anatomy is modified in that operation?
So basically the sleeve gastrectomy. (VSG) as the name suggests is that sleeve meaning you make a tube of the stomach gastrectomy means you’re removing a portion of the stomach. So essentially what we’re 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 on proof that up to three years there is a significant drop that is maintained in the ghrelin levels. Now, 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 we probably haven’t discovered as yet, because it’s a very complicated mechanism. Appetite and hunger control are very complex. So, that operation, basically the beauty of the operation is that it allows the food to go down the food by the stomach and the small part in a very natural, 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 are struggling with portion control. It’s a great operation, BMI less than 45. If that’s what the individual profile says, again, VSG Gastric sleeve is a good option because it allows the food to go down the natural passage, reducing the risk of developing nutritional deficiencies. That’s a great thing.

As far as the bypass goes, What are the main changes made there?
With the bypass as the name suggests, we bypass a portion of the small bowel which is the upper small ball and in the ruin why we made two joints so a small patch of the stomach and then the attach a segment of the small bowel to two there are two limbs basically the biliary limb and the alimentary limb most of the time surgeons would make an alimentary limb off about a meter or so which is about 100-110 centimeters. And most of the surgeons would have a biliary limb of about 75 centimeters 65 to 75 centimeters. Now, there are no written rules about it. But most of the surgeons would agree on that. Having said that, with the one anastomosis bypass, if the BMI of the individual is 50, or less than b, go for a bypass of about 150 centimeters of small bowel it’s only one joint.

When you’re doing that with BMI, yeah. What is that mechanism that you’re utilizing there?
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 a 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 effect, because the first bariatric operation just out of interest was wiring the jaws of the individual, you know, which is funny, because, again, you know, 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 nerve and the neural and hormonal signals that go from the gut to the brain that influence our hunger and appetite mechanisms.

So I guess the umbrella of it is you’re altering the hormonal responses, changing that gut-brain Brian conversation in many ways, as well as limiting the In both of the surgeries, absolutely,
there is a veil of enough scientific evidence to prove that there is gut-brain access. There is a two-way communication happening not just one way 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 Latrobe 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 mini gastric bypass surgery. So that is something that you’ll be really excited about, and we’ll be presenting it at a conference later in the month.

Around the area of THE GUT, can you tell us a little bit about your interest in that?
The fact is, the more you learn about the gut, the more you’ll realize that you don’t know enough, there’s so much that is unknown. That you know, and I think that is the reality that every new discovery, opening our eyes to so much that we don’t know. And that’s the beauty of it as well. , 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 when we are feeding a diet which is made up of processed foods, which is full of preservatives, chemicals, antibiotics you can find in lots of neat products., 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 lumen of the gut and the actual blood supply. So all these undigested particles, start to enter into the bloodstream, creating a state called dysbiosis and gut inflammation. This is this concept is not acceptable by every gastroenterologist, every physician, because clearly there will be people who will challenge these views. But I guess my only question to people is that our current model of treating patients with only pills and procedures is not working.
If you see the overall incidence and you look at the Medical charts, actually, they present numbers Every quarter, our incidence of obesity, cancers, diabetes, and cardiovascular problems is only going up. So BMI, even with the rate of these procedures is exploding and always other public health programs that are targeted towards diabetes and get up and, move more, 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.
And I think my biggest concern is that it is already the point where it’s unsustainable like Australia takes pride and I have worked in the system for over 20 years now. And I can see the hand on my heart, we’ve got a beautiful ethical medical system. It is really well ordered to be provided. 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 don’t go to hospitals if you have a problem, I’m saying that you can do things right now. I often say your kitchen can change your health, destiny.
Just your kitchen. So what you’re putting in your mind, the kind of processed foods, the kind of where 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 metabolism. And there’s just one example.
And I think my message in that token 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 and lengthening our lifespan. But I guess the bigger question is, it has not served us well in improving our healthspan. Because of the convenience, and the lifestyle changes that we have embraced accidentally, which is not intentionally we’ve got, the 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 talked about in the book, is really not eating in front of the screen, and connect with your food to a small example. But that itself allows you to appreciate the tastes of what you’re eating. But also realizing when you’re full, you gotta say thank you, and then you push it up. Whereas while you’re eating in front of his screen, you are so disconnected, you just don’t know when you finish the whole pizza! And you’re still hungry. Because you haven’t recognized actually, at the moment.

I’ve also read, if you’re happy, or you’re content and you’re eating, you also draw more nutrition from that food. And that comes down to the relaxation state.
Correct. And what you’re talking about is the relaxation response, basically, which is the entire opposite of 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 starvation, there is famine, and it tries to conserve every calorie that you’re taking, and you just wonder that you’re eating healthy, but you’re still gaining weight.
So a lot. that multifaceted. approach to health
Stress Management is a big part of weight management because if you’re stressed out, and if you’re not sleeping adequately, you cannot expect a lot. Exactly. So these are all different strategies that we talked about in the book, and in the workbook and the journal.

What a great combination.
Correct medical intervention and a more balanced approach to health and nutrition can be the key to turning in someone’s life around to a whole new direction!