Dec 22, 2015

Interview Transcript

Dr. Miller: Which weight loss surgery is right for you? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today, The Specialists, with Dr. Tom Miller is on the Scope.

Dr. Miller: Hi, I'm here today with Eric Volckmann. He's a bariatric surgeon and Professor of Surgery here at the University of Utah. I understand there are three main types of bariatric surgery. What do we offer here at the university?

Dr. Volckmann: Here at the University of Utah we offer laparoscopic gastric bypass. And we probably do that for about 60% of our patients. That's a great operation for patients with diabetes. It has the strongest effect on Type 2 diabetes.

Dr. Miller: And it's the one that's been used the longest. Is that right?

Dr. Volckmann: Yes. We know the most about this operation. Some surgeries come and go, but gastric bypass is still considered the gold standard weight loss operation.

It's also a great operation for people who have heartburn. If you have heartburn and you have this surgery, it makes it go away. Most of the other options out there may cause heartburn in up to 15% of patients, but they still provide very good weight loss.

Gastric bypass also provides great weight loss in terms of the amount of weight loss, about 60 to 80% excess body weight loss, very durable. So as patients get up into the heavier BMIs, BMI 50 or more, I generally will recommend this operation.

It's not right for everyone, though. You can have ulcers with the operation if you use nonsteroidal anti-inflammatory drugs. So those are things like aspirin, ibuprofen, naproxen, or Aleve.

It's also not a good option if you need chronic steroids. So patients who maybe need weight loss surgery so they can undergo kidney transplantation, or any steroids for life afterwards. Anyone who would need chronic steroids for any kind of autoimmune condition would not recommend this operation.

Alcohol potency after gastric bypass goes up 300%. So people with personal history of alcoholism or who drink alcohol regularly may not want this operation.

So people who aren't maybe good candidates for gastric bypass may want to consider sleeve gastrectomy, which has weight loss that's similar. But a little less, 50 to 70% excess body weight loss, hasn't been around as long. We don't know much about it. And about 15% of patients can have heartburn afterwards with that surgery.

It's largely replaced adjustable gastric banding. It's something we also offer. That tends to be something that may be as good for somebody with a body mass index of 35 to 40. We're largely moving away from that in this country because about 40 to 60% of patients who have an adjustable gastric band placed might need a subsequent operation to have it repositioned or removed.

So sleeve gastrectomy has really sort of replaced adjustable gastric banding, not only in this country, but in the world.

Dr. Miller: Do you see sleeve gastrectomy as becoming more important in the long run? Or do you think gastric bypass will be what we continue to do for some time?

Dr. Volckmann: Well, it depends on swings a lot. And sleeve gastrectomy is now preformed a lot more commonly that gastric bypass, but we don't have a lot of long term data. And as a bariatric surgeon, I still like gastric bypass a little better. I see better weight loss with it and a little bit more reliable weight loss, and possibly more durability. For sure, better treatment of diabetes.

Dr. Miller: I think at the end, our patients that have issues about whether they should undergo bariatric surgery need to talk on an individual basis to you or one of your physicians about what would be correct for them, or best for them. So you really don't know that until you actually take a history from them and then involve them in the conversation.

Dr. Volckmann: That's exactly right. Before patients come in to our clinic, we have them go to a bariatric information session where I talk about all the differences between the surgeries. And so normally when patients come to see me they have a good idea of what surgery they want. And we tend to be on the same page.

I look at my job is to help patients decide on an operation that will be good for them in the long term, and won't cause them harm. And what I tell patients is just what you said, that there's not one right operation for everyone. It really depends on your individual health and medical problems as to which operation will be right for you.

Dr. Miller: So basically, these procedures now are laparoscopic, meaning they're minimally invasive. And that's a change from 10 years ago.

Dr. Volckmann: Absolutely. I think that the ability to do these operations with a small scope and long, narrow instruments has really enabled bariatric surgery to become much more commonplace. Because when you talk about doing surgery in the setting of obesity, one of the biggest things we had to contend with in the past was the risk of wound infection and hernias, which are just not that common with laparoscopy. And when they happen, they're very minor.

Dr. Miller: So your time in the hospital after surgery is less and it's just much improved. I think your complication rate is much lower now with surgeries. This is a time now to really think about bariatric surgery. Where in the past I think the people were fairly concerned about the complications being limiting.

Dr. Volckmann: Yeah. Nowadays we have looked at the outcomes of bariatric surgery, and the risk of having a complication or dying from surgery is about the same as it is having your gallbladder removed, which most people don't think twice about.

Dr. Miller: That's really impressive. One of the other things I might ask is do most insurance plans cover bariatric surgery now?

Dr. Volckmann: The majority of plans do. It is somewhat employer based, however. Your employer contracts with your insurance company, and sometimes it's cheaper not to have a bariatric benefit listed. So we always have people check with their insurer and make sure that it's covered before coming in to see us. But I would say the majority of plans cover bariatric surgery in this day and age.

Dr. Miller: Does Medicare cover bariatric surgery now?

Dr. Volckmann: Medicare does, and from a patient perspective it has some of the best benefits in terms of access to care.

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