Melanie (Host): Welcome to Brian Health Podcast. I'm Melanie. Today we are talking about weight loss surgery. Joining me is Dr. Chris Sipe. He's a general surgeon with Brian Health. Dr. Sip, thank you so much for being with us today as we get into this topic. And wow, there's so many tools in your toolbox today.

It's really an exciting time in your field. But I'd like you to start by kind of giving us a working definition of obesity And the economic burden. I mean, we're really seeing an epidemic in this country with our children and with our adults. Speak a little bit about how you define it so that then we can talk about what we're doing about it.

Chris Seip, MD: You bet, Melanie. Thanks. And yeah, it's a pleasure to be here. obesity, when we start talking about that and specifically. I'm a surgeon. So when we start talking about patient's who might be candidates for, say, weight loss surgery because of their obesity, we in general are talking about patient's who probably weigh around a hundred pounds over their ideal body weight.

And so that means when we calculate what we talk about in medicine, the BMI, uh. Is gonna be around a BMI of 40. so for the average person, that would be, if an average person is 70 kilograms or 150 pounds or so, that's gonna be weighing around 250 pounds.

So it's a, Fair amount of weight for people to try to lose. Unfortunately too, just like you suggested, when you look at our statistics in society, we know that and it varices a little bit by region, by state, in the country, but in general. The population is at least 40% overweight, And that would be, say, BMIs between 25 and 35.

And then the rates of morbid obesity. So like I was just suggesting a hundred pounds over ideal weight, those numbers, approach 15 to 20% in some states. So it's, it's a really common problem, one that impacts so many aspects of life. It's an expensive problem from a medical. perspective to take care of illnesses that are directly a result of the weight.

and So, It really does impact almost every aspect of, uh, life.

Melanie (Host): Well, I'm glad that you mentioned there are. Comorbid conditions as a result of obesity. Just speak a little bit about those, because I think that they have a bearing on why it's so important to consult your provider to discuss these kinds of tools that we have because they cause so many complications that then lead on down the line.

Chris Seip, MD: Yeah, they really do. And they, compound each other, so some of the more common associated comorbidities, which are just illnesses that are directly related to obesity. would be type two diabetes, which is an insulin resistant condition. And with that condition, there's numerous other systems that are involved, as a consequence, which include the kidneys, which include heart disease, risk of stroke, goes up.

And so hypertension included in that group. so there's, several things that as a result of maybe having type two diabetes, the other systems are gonna be impacted as well. And it's not just the diabetes and or cardiovascular disease that's at-risk. There is also one of the more common conditions is obstructive sleep apnea.

And that condition also it's most commonly, somebody whose, uh, symptoms are snoring at nighttime. And that directly impacts other systems as well. So it's a pulmonary condition, but it, impacts the heart. Pretty substantially. and patient's who suffer with obstructive sleep apnea, they really feel miserable. Their energy levels are completely down.

because of that, their stress level or cortisol levels are really high. and as a result of that, their metabolism is completely messed up. And so it's a vicious cycle. All of these things spiral out of control. Trying to get the weight off, uh, oftentimes medically is really difficult, especially when you're looking at the amount of weight we're talking about.

And so that's, kind of where my specialty comes into play. weight loss surgery has statistically been, well documented over decades, to really provide substantial weight loss.

Melanie (Host): Well, as I said at the beginning, This is such an exciting time. There are so many options, and before we discuss those, what had been done previously, Dr. Sipe, in terms of weight loss, were we just kind of throwing up our hands and telling people to exercise and eat less?

When we think of these histotripsy weight loss efforts, which. People found very, very difficult. I mean, there are weight loss programs out there, And so I'd like you to just speak briefly about some of the things that we used to do and why we're looking at all of these different interventions now, And then you can tell us about what's available now.

Chris Seip, MD: Yeah, you bet. So for decades it's primarily been just like you suggested, you need to exercise and you need to eat less and unfortunately, when you look at studies. The success rates with those two measures or lifestyle modification alone are really discouraging. 5% of excess weight on average can be lost over 12 months with those two efforts alone for the average person.

And that's not enough to impact any of the illnesses that we're talking about. And so again, that was decades now, surgery has been around for a long time. It's been around since, uh, maybe the mid 1970s, and that's evolved in what it would've originally looked like to what it looks like now.

some of the more durable procedures like a gastric bypass. They've been around for 30 years or so. maybe just a bit longer. Those have also evolved as to how that's done now. And so now, as opposed to telling people you just have to change what you eat and exercise more, we do have some al options surgically.

There are also some newer medications coming down the pipeline that help with, weight loss. So all of those things, when you look at any given patient, we need to, number one. They will need to change their lifestyle. that's part of the deal. even with a surgery, even with some of the newer medications, it still requires those lifestyle modifications, but we really can achieve much greater results, with weight loss.

we're talking about weight loss, but honestly we call it metabolic, surgery. And so not only. Do the patient's lose weight, but really we affect their metabolism and that's, probably the greatest. When you look at long-term stuff, changing their metabolism is the key. and some of the newer meds, they also work by changing metabolism.

So they provide weight loss, but they really, they dramatically change this system.

Melanie (Host): We're gonna touch on some of those meds later on, but I love for you to tell us the options that are available because they, some of them are tried and true, and some have changed a bit over the years.

Chris Seip, MD: So gastric bypass, like I mentioned, would've been done around the early nineties to mid nineties when it started, And that was done through an open, regular big incision. has persisted and it's been a gold standard for weight loss for many years. It works by restricting how much a person can take in, but it also bypasses a portion of the intestine, so there's malabsorption of nutrients And so calories that are taken in.

Are not absorbed, even though what you take in is restricted. And so that, for a lot of patient's has been the, uh, gold standard. It provides 70 to 80% of excess weight loss potential. the alternative surgically when you look at them. Another one is a duodenal switch, which is somewhat like a gastric bypass.

There's a restrictive component to that, as well as a malabsorptive, bypass segment. And so that similarly will provide great weight loss, 70 to 80% of excess weight, both of those because of rerouting the intestine and bypassing a portion of absorption. They do have long-term nutritional consequences. And so Those are patient's that have to be followed lifelong for many of the nutritional potential deficiencies.

Really, one of the other main stays of surgery now is a sleeve gastrectomy, and that's where we just take out 75 to 80% of the stomach and leave behind a long gastric tube, which does a couple of things. It is restrictive as to how much a person can take in.

But it's also metabolic. The part of the stomach that's taken out with that surgery really contributes to much of a person's hunger desire for food, the problems with insulin sensitivities. So when we take that part of the stomach out, it does change immediately those hormonal things. and that's a consequence of the surgery that's immediate and longstanding, durable.

so the sleeve gastrectomy for a lot of patient's when it's considered also one of the lower risk procedures is for many people the right decision. Those are the three mainstays, the gastric band that has been, around in decades now. It's been probably 25, maybe just longer years. it's fallen out of favor to some degree because much of the time, when you looked at average weight loss with a band in place, which was a mechanical device put at the top of the stomach to restrict how much a person could take in, it had many potential failures from a mechanical perspective.

It also had long-term complications of erosion and or, malpositioning requiring additional surgeries. Most patient's didn't achieve over 50% of their excess weight. And so as a surgical society, we really have felt like if you can't get to 50% of excess weight off, it's really not something that should be considered as a, uh, longstanding option for a patient.

So it's kind of fallen out of favor anymore. We take more bands out than are put in. I'm, I'm certain of.

Melanie (Host): Yeah, that's really interesting. That was a great explanation of the types that you offer. So there are parameters. This isn't something someone can just walk in and say, okay, I'd like a sleeve gastrectomy, can you please tell us the parameters for bariatric surgery as you look at your patient's, what they have to go through.

For sleeve gastrectomy or bypass, And what you tell them every single day about these parameters, why they're so important.

Chris Seip, MD: Yeah, you bet. So in general, when we look at people who we talk about as candidates for these surgeries. Again, it's back to the BMI as one of the, the first things we look at and a person with A BMI that's 40 or over, because that puts them at around a hundred pounds on average, over their ideal body weight.

Those are people that immediately we think, yep, even without other associated illness. Is they would be a candidate to talk about surgery. And in that, if a patient doesn't have those illnesses at this time, it just means not at this time, they very well down the road are going to, And so it's a preventative thing for patient's without illnesses.

But when you look at patient's who do have those comorbidities in place, especially type two diabetes and cardiovascular disease or sleep apnea, we lower that criteria down to A BMI of 35. And even for some studies now, it's well documented. The BMI is down even to 30 because of this metabolism component of the, uh, surgeries.

If we offer that to a patient with type two diabetes and A BMI of 30, it cures their diabetes. It'll cure patient's with higher. BMI also, but because of that metabolic change. these surgeries in general would be offered for specifically type two diabetics down to A BMI of 30.

if those other comorbidities, aren't present, then we usually stick pretty strictly to that 40, BMI and above. and certainly those patient's stand to benefit terrifically by losing substantial weight.

Melanie (Host): Dr. Cype, what do you want them to do if you've discussed this with them and it's a shared decision-making in advance of surgery, should they be trying to lose weight? Should they be exercising? Are they getting counseling? Because I know that's a part of it as well.

Chris Seip, MD: Yeah, absolutely. We put all patient's preoperatively. We'll, even honestly, we do now, I've done, in most programs, we'll do a either monthly or. every other month seminar where any potential patient who's considering this comes in to have a thorough understanding. It's presented usually by the surgeon to discuss, like, This is the reason that we're talking about this.

Are you a candidate? And we really to educate them about what's involved with the preoperative process, what goes on in the OR And what the postoperative process looks like. And so then all of those potential candidates are plugged into a system. If that's something that they remain interested in and preoperatively, then we get full medical evaluation.

We get also psychological evaluation. we have most patient's seen by pulmonology and cardiology to assess what their current illnesses are And what their future risk might look like. And then really try to pull that all together for the individual to see what's their potential benefit. To go through this, make it sure that they have a good understanding of what the risk is, but also on the other side of it, what their, success might look like.

And we do encourage them, even from the very beginning to make those lifestyle modifications. we used to have criteria to say, patient's who were, say super morbidly obese, where we'd be talking about BMIs over 60, that they had to lose a set amount of weight coming into the surgery before we could consider them.

What you find if you've done this long enough, is that that's a really difficult thing. There's a reason those patient's have gotten to the point they are, and to require that preoperatively for most of them isn't gonna be successful. so a lot of times they'll be down some as they come into the process, but they don't have the benefit of the surgery in place yet.

So, we encourage the lifestyle modification knowing that there's success preoperatively. Will be difficult and postoperatively at least they'll have those, changes in place to really, catapult themselves into the success.

Melanie (Host): And as we say, This is a tool And for people that think that This is an easy way out. It's not, and it is a lifestyle complete change, right?

Chris Seip, MD: Yeah, you're exactly right. I mean, we, we will hear oftentimes a family member or friend who has said that they're, going the easy route by doing this. And it's honestly not. It's really, it's just the person taking responsibility. and it's simply a tool, like you said, that really, in studies shows.

It's gonna help them be more successful than they could ever be without this tool, but it's simply a tool. 'cause it still requires all of the changes we just talked about to be successful.

Melanie (Host): Well, I agree, and I think that people that endeavor to do bariatric surgery are brave and taking charge of their own health, and that's really what's so important that we all have to be our own best health advocate. Now, as we think about what's going on today, Dr. Sipe, we see medical weight loss And we see medications that are out there like ozempic and things speak about the results.

For bariatric, as you've seen in your career versus these kinds of medications that are out there now, when you're talking to your patient's every day, what do you tell them?

Chris Seip, MD: You bet and even most recent studies just in the last several months, when we look head to head from a surgical weight loss perspective versus even the newer medications, hands down, surgery beats them. Every study done. so when you talk about medical weight loss, even with the new GLP one medications.

In general, we're talking about patient's being able at most to lose 25% of their excess weight. And I just mentioned that we don't consider it right to put bands in people anymore because we couldn't achieve 50% of excess weight loss in patient's. So when we're talking about surgical weight loss, we're talking 50 to 70 and 80% of excess weight off.

And when you compare that to medical weight loss. It's not even in the same ballpark. So again, 25% versus 70 to 80% is a big difference. And the impact on their life is similarly, a big difference. The changes too, with these medications, There are consequences and side effects. And many times the patient has to be on them lifelong.

And so it's gonna be, that's the challenge. The thing that we don't quite understand yet in medicine is what that's really gonna look like, these surgeries, like we're talking about. If we can get a patient, through them safely and into that postoperative lifestyle, they can be successful. For the remainder of their life at keeping the weight off.

And so we really consider them durable, permanent, solutions as opposed to medication, which is not proven to do that yet.

Melanie (Host): Yeah, and I think that maybe even some of those medications might be for people that don't qualify for bariatric surgery. As you said, maybe they only have 10, 20, 30 pounds to lose. They're not in the morbidly obese category or the parameters that you've discussed here today. but it's always good to talk to your provider and get this information clearly.

Now, Dr. Sipe, what is it like? For the patient's, what is it like after surgery, lifestyle management, supplementation, going out to restaurants? What is life like as you've seen it for your patient's?

Chris Seip, MD: it definitely changes it. So what we hear back when patient's come in and, really the first month is the recovery process for most patient's. Once they're past that, it's into maintenance, as far as what they're able to take in and amounts and those things. So, so say when they go out to eat, what they find is many patient's actually ask if we can give them a medical card so that when they go somewhere, they can, be charged either order off the kitty menu or at least, have reduced portions to have to pay for.

Because they really, if they get a regular sized portion, they will not be able to complete the meal and will have leftovers for days. So if they're able to do that, great, but oftentimes, again, they just Are able to take less. And that's the thing they grow accustomed to.

it does take some time, and I'll tell you that patient's vary a lot as to how, quickly they adapt to how limited of, intake they can achieve. it's initially sometimes pretty surprising to them that, man, it's just feels like a. A fraction of what they normally were used to.

and they're full, And that sensation of fullness also changes. And so that's a learning process for most patient's. It takes maybe three to six months to kind of adjust and really see what, that looks like. With bariatric surgery patient's, we keep them and our studies really have shown that we need to keep them in close follow-up, to keep them accountable, keep, watching that they're not developing any problems or symptoms, related to the surgery.

And so for patient's after that, we follow 'em up pretty closely the first six months, And then we start to stretch that out. But for most programs, we like to follow those patient's out to five years to be sure that they've remained successful and kept the weight off.

Melanie (Host): This is really such an interesting topic and an exciting time in your field, really helping so many people increase their quality of life, and That is so important, and indeed, even possibly the length of their life and certainly all the pain And the comorbid conditions that go along with obesity.

Dr. Cype, I'd like you to summarize for us giving your best advice. For people who are severely overweight, what you want them to think about. when new surgeons get up and you have these seminars, what are you telling them to think about when they're considering bariatric surgery and including their family in these decisions and those support groups?

Chris Seip, MD: Yeah, you bet. So in general, when we talk about that with a patient, it's, what areas of your life are impacted by your weight? And for most people it involves every aspect of their life. And so it's not only that they have these other illnesses that can consume their time, consume their money.

and really limit their lives, but it's also their life is limited from an activity perspective because of the weight. Whether that's the relationship with their spouse, the relationship with their kids, or grandkids. they just can't do the things they want to do or even maybe were used to being able to do before.

And so when they, look at those things in life, we try to tell them that's how. Things are restricted and postoperatively, if we can get the weight off, Those are the things that will come back. not only, like you said, will we prolong their lives potentially, but we will improve the quality of the remainder of their life so that they can be more active, they'll have fewer illnesses to worry about, and as a result, have more fulfilling lives.

Melanie (Host): Agreed completely. Thank you so much Dr. Sipe, for joining us today and sharing your incredible expertise in giving us so much to think about for people that are considering bariatric surgery And the ones that we love. So thank you again for joining us, and I'd like to thank our Brian Foundation partner, union Bank, and Trust to listen to more podcasts from our experts.

You can always go to brian health.org/podcasts. That concludes this episode of Brian Health Podcast. Please always remember to subscribe, rate and review Brian Health podcast on Apple Podcast, Spotify, iHeart and Pandora. Until next time, I'm Melanie Cole.