What you need to know when considering bariatric surgery. Dr Leon Cohen explains the risks, benefits and results you can expect based on 15 years of keeping detailed records. It’s not just about losing weight, it’s about restoring overall health and quality of life.
Risks, Benefits & Outcomes of Bariatric Surgery
But what about the risks? A lot of people would want to know what risks are involved.
Dr. Leon Cohen: Yes, sure. All surgery, of course, has risks. But with sleeve as we’ve grown in our experience of it, those risks now have become really very small. In fact, statistically, having a sleeve gastrectomy is safer than having your gallbladder out. But of course, people who have had gallbladder surgery are often older and sicker and that accounts for part of it. But overall, bariatric surgery has developed into a very safe procedure.
Now, with the gastric sleeve, the two most important risks at the time the surgery is done, is leak from the staple line and bleeding. Leak is by far the most serious and devastating complication. And if someone gets a leak, they will get very sick very quickly. We will always have to reoperate on them, sometimes keyhole, sometimes open, sometimes several times. They could end up spending many weeks in hospital recovering and many months before they’re well again and they could even die. That’s how serious a leak is.
But fortunately, leaks in our series now have become very uncommon. And so for example, for the last six years, since 2010, we’ve done over 700 sleeve gastrectomies in the primary series and we’ve had one leak. And that was due to a staple line misfire. We got on to that very quickly and the patient recovered very quickly. But it remains the dominant risk.
Wouldn’t it be more of a risk if they didn’t actually have the operation as far as their health goes?
Dr. Leon Cohen: Well, yes. And so, if for example, someone has a BMI of 40, at the age of 40 and they do nothing about it, statistics would say that they have lost on average 12 years of life. And if they smoke as well as having that BMI, you can double that.
So surgery is all about balancing risks to benefit. But as our understanding of how the sleeve should be performed has grown, we have got those risks down to a very low level and also, our understanding of how to manage those complications when they occur.
For sleeve, the other small risk at the time of surgery is bleeding. That’s very manageable. In the medium to long term, the two issues with sleeve are some people go on to get a little bit of heartburn and reflux after surgery. But the deal there is that if they already have reflux as many of these people do and it’s due to a stretching of the diaphragm, what we call the hiatus, which is where the esophagus passes through the diaphragm to join the stomach, if that has become stretched and the stomach slipped up, that will give reflux.
We look for that at the time of surgery and we make the hiatus snug again. And if we do that, we actually find their reflux gets better. And overall, reflux after sleeve is probably around 2 to 3% of patients and it’s easily managed by a tablet.
In the long term, the issues with sleeve as it is with all obesity surgery, is weight regain. There is no bariatric operation out there that doesn’t have the same pattern. And that pattern is that people typically reached a peak weight loss with sleeve at around two years. They remain steady for a few years and then they slowly, slowly regain a little bit of their loss weight.
Is that because the stomach expands?
Dr. Leon Cohen: Yes, that’s probably one of the reasons, an important reason. So the sleeve capacity does increase a little bit over time. It approximately doubles by two years.
How do you approach weight regain? How can we stop putting it back on again?
Dr. Leon Cohen: And what we’ve learned about sleeve though is that how much weight you initially lose and how much weight you subsequently regain is largely dependent on three factors.
First of all, your starting BMI weight, well we can’t do anything about that.
The size of the bougie we use, which is a rubber rod we use to calibrate the width and therefore the volume of the stomach, we can do something about that.
And then the third factor is what I like to call the YOU factors. So that is how well you comply with diet afterwards. That is how well you comply with diet afterwards. That is how well you comply with exercise, how well you comply with follow-up. Now, those YOU factors probably account for about 15% variation in our outcomes between our very best and our very worst patients. And it’s those YOU factors that I want to concentrate on after surgery to make sure we maximize the effect of the operation.
So, that is what we have designed our whole program around to make sure that your follow-up is right and that the support of you is right. And also, that the education that we deliver during and after the operation is right so that you make the best use of your surgery.
So I think bariatric surgery is a tool. OK, we’re going to give you a bright, shiny, sparkly tool. And to begin with, you’ll feel that this tool can do anything and your weight loss is coming off and you feel invincible. But if you don’t look after a tool, it will rust. If you don’t look after a tool, it will break. And then when you come back five, six years down the track and you’re surprised that you’ve regained some of your weight, it’s because you haven’t looked after your tool.
I have a client who sabotaged all the good work by melting chocolate bars and putting them in a smoothie. That wouldn’t help, would it?
Dr. Leon Cohen: Well, that was commonly a problem we had with adjustable gastric band when the band was too tight and people would say, “I’m gaining weight. Can you put some more fill and make me tighter?” In fact, the opposite had to happen. We had to slacken them off a little bit so they could eat good quality solid food. We don’t tend to find that same problem with the sleeve because eating those high-calorie foods makes people feel uncomfortable.
But the other culprit in weight regain unfortunately is alcohol. And so, if people are drinking just half a bottle, one bottle a night, they’re probably going to be adding that extra amount of calories that will bring them over the threshold where they will start to regain weight.
What results can the patient expect from the surgery?
Dr. Leon Cohen: As we’ve been doing the surgery for the last 15 years, we’ve kept very detailed records on our database on what the outcomes are. And this allows us to predict fairly accurately where I think someone is going to end up.
Now, weight loss outcomes are measured in bariatric circles by what’s called a percentage excess weight loss. So that is, what your ideal weight is, what your current weight is. And the percentage of that weight that you lose is your excess weight loss.
Now, if someone starts off with a BMI of say 55, that excess weight loss maybe 70. That excess weight maybe 70 kilos. If someone starts off with a BMI of 35, that excess weight may only be a matter of 20 kilos.
So someone with a very high BMI, they’re going to lose more kilograms than someone with a low BMI but it will look less as the percentage of their excess weight.
We talked about those two important pre-operative factors, the size of the bougie and the starting BMI. So for the sleeve gastrectomy, the size of that bougie has evolved over time. So when I started doing sleeves 14 years ago, we used a bougie that was about that wide, what I call 50-fringe. And we did a hundred of those and we saw a peak weight loss of about 65% excess.
In 2006 to 2010, we dropped down to a 40-fringe bougie which is what I now call my mid-size bougie. And we saw 75% excess weight loss, so about a 10% better excess weight loss.
Now, we currently use a 36-fringe bougie since 2010 and that’s what I call the slim bougie. And for those people we typically see around 82% peak excess weight loss at two years. By five years, it’s sitting around 72%. And we’re waiting to see what ten years brings.
Now, the indication for re-operation if people have regained their weight is really much more regain than that. So we are probably not going to even consider doing revisional surgery on someone until that number has got down below 50% or if they’re starting to redevelop some of their illnesses like their diabetes.
And the beauty of the sleeve gastrectomy and in fact one of the reasons why I think it’s a great operation is that we can measure the volume of the sleeve. And if the weight regain is due to an excessive stretching of the sleeve, there is nothing to stop re-sleeving so we can bring that sleeve volume back down to where it was before. And I’ve done that on about 30 occasions on both my patients and other patients and have been rewarded by getting them back on track.
But surgery is not the only answer to weight regain. And we really need to address all the other factors. So Dennis, I have a concept of bariatric surgery which says that it’s like a three-legged stool. You’ve got the weight of the patient sitting on the stool and you have the three legs. And those three legs are the right surgery, the right education and follow-up, and then the patient factors.
Now, if any of those legs are weak then the whole stool is going to topple. So we have to get all of those legs right. Read more about our results.
That’s weight loss. What about the other aspects of health like maybe diabetes or people who have problems?
Dr. Leon Cohen: Yes, absolutely, Dennis. And that should be the fundamental reason why we’re doing the surgery. We’re not just trying to get people to lose weight. We’re trying to restore their health. And we know that there are so many diseases that are linked to their obesity and fortunately most of those will get better as they lose weight.
The cardinal culprits driving this surgery of course are diseases like diabetes, type 2 diabetes.
Dr. Leon Cohen: Sleep apnea, high blood pressure. But there are also other things like infertility in women and polycystic ovary syndrome. There’s arthritis because of the load on the joints. And there is even conditions like psoriasis of the skin. We now recognized that that dramatically improves with weight loss.
So, all of those conditions we would expect to substantially improve and in many cases, completely resolve after bariatric surgery particularly things like sleep apnea and diabetes. But I don’t think with regards to type 2 diabetes that we can ever claim that we cure the condition. I like to think of diabetes as being a continuum. And so, you start off here with normal blood sugar and normal pancreatic function and you’re not diabetic.
But over time and with age and with obesity, your pancreas starts to fail but paradoxically, has to push up more insulin because your fat is making it less active and doesn’t work as well. And at some stage, your blood sugar has reached the point where you’ve classified as diabetic and your doctor may have put you on one tablet and then a second tablet and then a third tablet. And if your obesity continues at some stage, he may have even started insulin.
When a doctor starts insulin on a type 2 diabetic, it’s game over because their weight will just dramatically increase because insulin is a growth hormone and it makes you store fat.
And what bariatric surgery does is drag you back somewhere along that timeline. Now, how far it will drag you back on that timeline depends on your age, your level of obesity, how long you’ve had diabetes, whether or not you are now on insulin. So in all cases, we would expect to improve a diabetic’s management. In the majority of cases, we would expect them to get them off most if not all of their medications but we can’t say we’re ever going to cure the condition.
And if patients live long enough as we hope they will, probably diabetes will come back down the track because of slow deterioration of their pancreatic function, which all of us, all of us experience over time, or if they regain weight that, that process will accelerate. So the impetus on diabetics of course is to have good follow-up and make sure we can address those things before they happen.
What’s really exciting is that there are now new operations. We talked about the metabolic operations that maybe applicable to patients who have lost weight but haven’t lost their diabetes by rerouting the intestine, reorganizing the way the food is delivered to the intestine. We can give that person a second kick against their diabetes, and that’s very exciting stuff that’s coming out at the moment.
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