For this Doctor Talks, we are going to be exploring the role of metabolic in bariatric surgery for the treatment of weight or obesity. And with me is Doctor Kyle Thompson.

He is a minimally invasive surgeon at Saint Joseph Hospital in Denver, Colorado. He completed his general surgery training at Saint Joseph's and then completed a fellowship in bariatric surgery, minimally invasive surgery, and flexible endoscopy at the Minnesota Institute for Minimally Invasive Surgery.

He's board certified in general surgery with a focus plastic designation in metabolic and bariatric surgery. And he is also board certified in obesity medicine.

Thank you so much for joining me, doctor Thompson. Thank you for having me. It's great to be here. So, can we just first talk about who should be considering surgery for weight loss?

Like, how does someone decide if that's something they should even be thinking about? It's a great question, and it's a very timely question. The American Society of Metabolic and Bariatric Surgery came out with new guidelines for who qualifies and who should consider, bariatric surgery in 2022.

And prior to that, the guidelines that we used were from 1991. So we were due for an update. There's very little in medicine that has not been updated over the last 30 years.

And the unfortunate thing is that a lot of insurance companies have not adopted these guidelines when it comes to coverage of bariatric surgery. But the guidelines that are current suggest that patients with a BMI greater than 35 should consider bariatric surgery, or those with a BMI greater than 30 with an associated comorbidity.

And those include things like diabetes, high blood pressure, high cholesterol, sleep apnea. There are some nuances to those guidelines based on your race.

However, those are the guidelines, that were recently published, by our national society. Like I said, unfortunately, insurance companies have not adopted these updated guidelines and the, more traditional guidelines that insurance companies use to cover bariatric surgery include patients with a BMI greater than 40 or those with a BMI greater than 35 with an associated comorbidity.

So you may ask, why did these guidelines change? And the reason is that surgery has changed a lot in the last 30 years. And specific and metabolic and bariatric surgery has evolved enormously over the last three decades.

When we think about the procedures that we offer and the techniques that we use to do those procedures, it's a much different field than it was, in the early 90s.

The procedures now are almost exclusively done minimally invasively, meaning we do them with small incisions and a camera. Oftentimes the biggest incision is just bigger than a centimeter.

And that drastically reduces post-operative pain, shortens the recovery time, and most importantly, reduces the risks of complications from surgery. So we've certainly reduced the risks of surgery over the last 30 years.

And we've also seen improved outcomes. And a lot of that is outside of the operating room. And recognizing that the patients who have the best outcomes are patients who seek care at Centers of excellence, where we have multidisciplinary teams, including those with experience in obesity medicine, registered dietitians, nurses and APS who all have an enthusiasm for treating patients with obesity.

So I would encourage patients who may not meet the guidelines, that their insurance, recommends for bariatric surgery. But do qualify based on the 2022 guidelines, to consider meeting with a bariatric surgeon.

And they can talk about the pros and cons of bariatric surgery on their individual case. There's a chance that even after they go through that process, their insurance may deny the surgery.

But if that's the case, most surgeons are willing to do an appeal. Or in a peer to peer, visit with the insurance company, not to try to advocate for patients because we recognize that there are patients who would benefit from bariatric surgery even if their insurance doesn't cover it.

Yeah. And I think that, you know, we're stuck at the same place. I prescribe mostly medications, but I do help patients who are getting ready for surgery or after their surgeries.

And, you know, there's this line between what insurance wants to cover and what's good and appropriate medicine. And they are not always the same thing.

The insurance companies have totally different priorities than you or I do as physicians, and that our patients do for their lives. So, yes. Let's not let the insurance companies dictate medicine because they really not the ones who who should be deciding what makes sense for someone's health.

They're they're focused really on what makes sense for their bottom line. So those are sort of the criteria, right? Like it is sort of weight based and based on what medical conditions you may have that are related to your weight.

But, you know, I often have people who will come in to consult with me who are more interested in medications or using nutrition or exercise. And I actually think they would be a great candidate for surgery, based on what they've told me.

But they're they're hesitant to consider it. So what would you tell someone who, you know, really has maybe struggled for a very long time with their weight has quite, you know, a lot of weight that they could lose to improve their health.

Why? Surgery might be something to at least open their mind to. Absolutely. And I think it's a great question and a conversation we have with patients very frequently, even when they're coming to see the surgeon to talk about weight loss.

Not everybody's convinced, even at that point, that surgery is right for them. And I think, like every decision we make in medicine and in life, it ultimately comes down to risks and benefits.

And when we look at the risks of bariatric surgery, we know that it's as safe, if not safer, than having your gallbladder taken out or having your hip replaced.

And as far as the benefits go, we know that there's no other treatment for obesity that has the same outcome, comes in the same durability compared to weight loss surgery.

So there certainly is, you know, more risk involved with surgery than there is with, you know, a diet or an exercise regimen or even some of the medications that are now being prescribed for weight loss.

But when it comes to, the overall risks of surgery, the overall risk is incredibly low of having a complication. And we have outcomes that, just can't be matched with diet and exercise alone.

And a lot of patients that come to see us, have tried countless diets, countless exercise programs, they've tried medications that they may be able to afford or that their insurance covers.

But those patients, even if they're not seeing the results that they desire, should not feel like a failure by any means, because we know that there's, you know, millions of people out there who are having the same experience.

Bariatric surgery is not the easy way out. It's, invasive procedure. There's a recovery process. There's preoperative requirements before surgery. So patients really have to be dedicated, to going through all those things to have a successful outcome.

But we know that the outcomes from surgery, just aren't parallel with any of the other options that we have, for obesity at this point. Yeah. And I think when you say that, you know, to be clear, what surgery offer is that we really, can't achieve with lifestyle alone and usually really can't achieve with medicine is the amount of weight that can be lost, is often much higher with surgery and the duration or how long people keep the weight off, is much more likely to be a long term success or a long term, durability of that weight loss when when they have gotten a surgery?

Absolutely. And I think, you know, the easy way to put it is that it's definitely higher risk than diet and exercise. But just like you alluded to, it's certainly a higher reward.

And I think, as you know, physicians and as a medical field for a long time, we haven't done patients a great service when it comes to treating obesity.

We haven't looked at it as a disease. A lot of people have said, eat less, exercise more. But we know that diet and exercise alone have about a 95% failure rate when it comes to treating obesity.

There's really nothing else in medicine that we recommend as physicians that has a 95% failure rate. So that's why I think, you know, the field of obesity medicine and the medications that are coming out is certainly an exciting field.

Bariatric surgery has been around for a long time. But we only operate on about 1% of people every year who qualify for weight loss surgery. So there certainly are many other people out there who may benefit from surgery.

And so consider it. And if they have insurance coverage. Yeah. And and it is, you know, surprising how few people utilize, surgery. And so hopefully, you know, the information that you provide today will, will encourage people that, that it should be considered an option.

And we talked a little bit about, you know, some of the risks and that it is, you know, no more risky than other surgeries you're getting. And I think that this is something we have to consider for any intervention in medicine.

Whether it's one of the modifications that I prescribe for obesity, whether it's surgery. All of these things are going to have risk, and we should be using them for a medical reason.

But we know that obesity is contributing to things like diabetes, heart attacks, stroke, cancer, sleep apnea, so many different medical problems. And so if we weigh the reduction in your chance of having a heart attack, your, reduction or even curing diabetes, which we should talk about, from surgery versus the risks, then for many people, it really does make sense to, to consider it.

Absolutely. And, yeah, I think a lot of people look at this and think of it as a cosmetic procedure. But just like you said, the benefits, and this is why we call it metabolic and bariatric surgery, because there are hormonal changes that take place.

There are endocrine changes that take place. There are countless changes that take place not just related to the weight being lost, that lead to an overall improvement in health and actually an overall extension of your life expectancy.

So we know that patients, who are living with obesity face far more risks, than those who have surgery. And the way we think about that is that that lifelong risk of obesity far outweighs the risk of having a complication from bariatric surgery.

On the metabolic side, I think it would be particularly interesting to talk about the effect surgery has for people who have type two diabetes, because I think that is something that has been completely underappreciated and under discussed as a treatment option for people with type two diabetes.

Can you talk about the unique benefits that people with type two diabetes have from surgery? Yeah, it's remarkable the hormonal changes that we see immediately after surgery and a lot of those are hormones that are now making it into the popular press like GLP one.

I say that, bariatric surgery, some of the surgery options that we offer are like a natural GLP one agonist. And, we see that patients who have had type two diabetes, adult onset diabetes that have been treated with medications and insulin for years or decades, oftentimes will have surgery and leave the hospital the next day without any requirements for the medications that they're taking for diabetes.

So it's just remarkable. Before a patient loses a pound after bariatric surgery, the hormonal and metabolic effects that are taking place immediately.

Yeah, I mean, it's pretty cool for someone who has had to deal with checking blood sugar and checking insulin and counting every carbohydrate they eat, because of of their diabetes, to be able to walk away, you know, not always, but oftentimes not having to do that.

And it's it is. And I think, you know, we talk a lot about the, you know, the outcomes, the benefits of surgery. But you just alluded to some of the small things that make a huge difference in patients lives.

So not having to inject themselves with insulin every day, not having to poke themselves in the finger countless times a day to check their blood sugar.

Those are things that can actually lead to an improved quality of life after bariatric surgery. Well, let's talk about how surgery work, because I have a feeling that most people listening, have sort of an outdated idea of of how surgery works.

So tell us the real deal on how these surgeries and procedures work. So surgeries now are exclusively done minimally invasively. So this is laparoscopic sometimes robotic assisted surgery.

And we're doing these types of surgeries through very small incisions. So the majority of them are less than a centimeter. Usually one incision is a little bit bigger to incorporate, or to allow us to incorporate the use of a stapler during a surgery.

But the pain afterwards often is, well controlled just with over-the-counter medications. The recovery time is much shorter with laparoscopic surgery and a lower risk of complications like we talked about earlier.

Now, when we do surgery, we offer a few different options. And there's really been no one single option that's been proven to be better than any other.

So really, the choice of which surgery is best for you should really be a shared decision making process that you go through with your surgeon before, you sign up for surgery.

And in our program, we offer the sleeve gastrectomy, which is the most popular option for bariatric surgery around the world at this point. We also offer the gastric bypass, which historically has been around for about the longest.

It's probably the most well known. As well as, assadi or a single anastomosis duodenal ileostomy, which is a modification of a duodenal switch. So those are the three options that we offer in our program.

And each works a little bit differently. When it comes to the sleeve gastrectomy, we are removing about 80% of the stomach. So that's, you know, the majority of the stomach, we're taking the stomach from the size of a football to about the size of a banana.

And the main way this surgery works is by restricting how much food and liquids you're able to eat afterwards. So patients feel full faster. They have less hunger.

And that's what leads to significant weight loss after surgery. There are some hormonal effects. Or removing the part of the stomach that secretes a hormone called ghrelin, which is, known as the hunger hormone.

But the effect of those hormonal changes isn't as profound as some of the other hormonal changes we see with the gastric bypass or the safety. So the sleeve is the most popular choice, I think, because it's the safest choice.

And, for an otherwise healthy patient who maybe, you know, in their 30s has no other, related diseases. The risk of having a complication is typically less than 5%.

And that's all complications. That includes, you know, bleeding, infection, having another surgery, coming back to the hospital. So that's less than 1 in 20 people who are having any type of post-operative issue.

We see about 60% excess weight loss after, sleeve gastrectomy and, the sleeve gastrectomy has been around for about 10 or 16 years now. So we don't have a lot of great long term data looking at decades and decades.

It's, outcomes after surgery, but it has continued to maintain its popularity here over the last decade. And, I think because of the safety profile, this procedure, it's going to be around for a long time to come.

The gastric bypass has been around for close to 50 years, and, this is also done laparoscopically. It's a little bit more of an advanced technique because we're not only operating on the stomach, but we're also operating on the small intestine.

And, what we do during this procedure is we divide the stomach into two parts, a smaller part called the pouch, which is about the size of an egg. And that's what food passes through.

So because that pouch is so small, it restricts how much food patients are able to eat after surgery. And we then rearrange the small intestine so that the rest of the stomach and about the first few feet of the small intestine are being bypassed.

That leads to some pretty significant hormonal changes. And this leads to about 70% of excess weight loss after a gastric bypass. So it's a little bit higher reward, but it comes with a little bit higher risk.

The gastric bypass again has been around for decades. The reason it's been around so long is because it works. There's great long term studies looking at, the durability of this procedure for weight loss and the outcomes for weight loss, as well as curing things like diabetes.

It's one of the best operations that we have to actually cure diabetes, as well as things like acid reflux. The final option that we offer in our program is to say to you, yeah, this is actually the newest procedure that was endorsed by the American Society of Metabolic and Bariatric Surgeons for Bariatric Surgery in the United States.

And this essentially combines aspects of both the sleeve and the gastric bypass. So we first do a sleeve, in a similar manner as if we were just doing, a sleeve.

We remove about 80% of the stomach, and then we divide the very first part of the small intestine and make a connection between that very first part of the intestine and the small intestine.

That's a few feet from the end of the intestine. So we're bypassing about half of the small intestine, which is even more than we bypass during a gastric bypass.

So this is really the highest risk and the highest reward operation that we offer. We see about 80% of excess weight loss after this surgery. And it's just a little bit higher risk, than the gastric bypass.

So typically for a gastric bypass, we see a risk of having a complication for an otherwise young, healthy patient. Somewhere between 5 and 10%. For assadi, it's pretty similar.

And so close to about that 10% risk of having a complication. And not all of those are serious complications. Some of those are just dehydration that require some I. V.

fluids. But certainly the gastric bypass and the kidney have a little bit higher risk of having a complication in the sleeve. So you talked a little bit about the excess weight that can be lost on on that.

Can you give a sense of, like what? That actually means, like, you know, in terms of how much weight someone can expect to lose? Yeah. So it's a little bit confusing because when we when we look at how much weight we expect people to lose with diet, exercise, medications, surgery, sometimes different language is being used around how much weight, whether it's total body weight loss or excess weight loss.

I think as a surgeon and as you know, surgeons in a field, we love to have great results. So we want big numbers when it comes to weight loss. So we talk about excess weight loss because it has the biggest amount of weight.

When it comes to describing to patients how much weight they're going to lose. So I think the easy way to put it is excess weight loss means if somebody is 100 pounds overweight over their ideal body weight, after a sleeve, you expect them to lose about 60 of those pounds after a gastric bypass, about 70 of those pounds and after it's 80, about 80.

Those pounds. Thanks. I think that that clarifies it a little bit because you hear 60% and you're like, wait, what? But it's of that excess weight. If you had 100 extra pounds, you know, you'd be losing 60% of that, that, that extra, and then long term, what can patients who have gotten surgery expect both in terms of results and like, what does their life look like?

So, long term results are difficult to study. So there have been some studies that have shown that the outcomes after bariatric surgery are better for weight loss than just about any other, method of weight loss that we offer, including medications, diet and exercise.

And really, the best study shows that about 90% of patients who have bariatric surgery lose and maintain over 50% of their excess weight loss. So to put that into similar terms as to what we just talked about, if a patient is 100 pounds overweight, there's a 90% chance that they're going to lose more than 50 pounds and keep that weight off long term.

Long term is a kind of a subjective term, but in this study they're looking at data over ten years. So that's really some of the best long term outcomes that we have.

And certainly it's important question for patients who are in their 20s or 30s and considering these options for surgery, things like the sleeve we don't have a lot of great long term data.

Whereas the gastric bypass, yes, it does come with a little bit higher risk, but we do have better long term data looking at the outcomes, more than just a few years after surgery.

And I think when you talk about like that weight regain, we will see some weight regain with almost anything we do. And I think one of the things I often find, I have to coach or cheerlead my patients on is that let's look at where you came from.

Right? If you lost 70 pounds but you kept off 40 of it, you've lost 40 pounds and kept it off. And that has had a huge impact on your health. And then, you know, something else that is important to keep in mind is no one solution has to be your final solution.

So if you get surgery and you lose a certain amount of the weight, you want, or you regain a little bit of weight, we can still layer other things on top of that.

So we certainly see patients in our clinic who have had good results from surgery, but they are wanting to lose more weight and they still qualify for a medication, and they can still use medications in addition to surgery or maybe they're starting to feel that weight regain happen or have a little more hunger come back.

Well, we can still use, medication or aggressive nutrition and lifestyle coaching to supplement the surgery. And so I think it's really important that if people are feeling like they're struggling after surgery or a medication or whatever they're doing to come back to, whoever they saw, so we can help them tweak what to do long term to, to have the most success, because we can almost always layer something else on if we need to.

I agree with that 100%. And that's one of the exciting things about, you know, the field of obesity medicine and obesity surgery and seeing how these worlds are colliding.

What I tell patients is obesity is a chronic and a relapsing disease. And we know that there's no treatment method, including surgery that's 100% effective or 100% durable.

So even though we do, bariatric surgery is the most effective and the most durable, having a little bit of weight regain is common after surgery. And that's one of the reasons why we encourage long term follow up.

We would love that for that to be with the bariatric surgeon. But I think as long as it's with somebody who has some comfort, treating obesity, whether that's a primary care physician and obesity medicine specialist or a bariatric surgeon, it's great to go into the office at least once a year and talk about your weight.

If you've had bariatric surgery. And sometimes that, visit is just a congratulations and a hug because people have lost the weight and kept it off. Other times we start to see that creep for maybe one year.

It's 5 pounds. The next year it's 10 pounds. And that's when we can offer different things to help treat that. Obesity, whether it's medications, getting plugged back in with a dietitian, or even considering revision or weight loss surgery.

But I don't think patients should ever feel like a failure if they start to gain that weight back. My analogy that I use when I talk to patients is, you know, similar to cancer.

So when we treat cancer, we often use medications like chemotherapy. We often use surgery. And unfortunately, cancer is also a chronic and a relapsing disease.

But we never blame a patient if their cancer comes back. We should never blame a patient if their obesity comes back either. And we really need to do a better job as a field and as a profession to offer all of those options, including, what we just talked about with medications, revision or surgery, to help patients maintain that weight loss and maintain that success that they initially had.

I like that's a really powerful way to think of it. That, you know, we would never think of that as a failure of the person who has cancer. And we would, of course, want them to come back and and want to treat that.

A lot of people will get a little nervous or have some horror story of someone they knew of, you know, long term side effects from surgery or never being able to eat a certain food again or, having to take vitamins forever or whatever sort of, you know, complaint that that they may perceive from the surgery long term.

What does life really look like for someone long term when they've had surgery? Yeah. So lives are certainly different after bariatric surgery. And that's one of the reasons why we have such an in-depth preoperative process, with our patients, to make sure that patients understand what they're getting into and what they're signing up for afterwards.

That being said, there's very few things that fall into the always or never rule. So there certainly are exceptions. And we certainly want to try to accommodate patients as best as we can.

Because we know that the benefits of surgery far outweigh those long term risks. But some of the big changes, even initially after surgery, are really focusing on hydration.

So making sure patients are trying to get about 64oz of water a day, and that starts even the day of surgery. So right after surgery, patients are going to be able to drink liquids.

It's one of our benchmarks to know when a patient is ready for discharge is when they're drinking enough to stay hydrated. We also really push protein intake.

And in those first couple of weeks after surgery, that's often including protein shakes as patients are on a liquid diet. But starting about two weeks after surgery, patients are going to start incorporating soft foods and eventually regular foods into their diet.

And we want patients to get about 60 to 100g of protein a day. We encourage patients to continue to follow up with our dietitians after surgery, and they will often see our dietitians even more frequently than they see me as the surgeon.

Because long term outcomes really, rely on diet and exercise to help maintain the weight loss, that we get with surgery when we use it as a tool. So we encourage patients to avoid foods that are, high in sugar, high in carbohydrates or starch.

And really focus on protein intake. Yeah. And I think that's like, you know, key to say, like there are going to be some nutrition things. You have to be intentional about lifelong.

But that's pretty much the answer. Even if you don't get surgery, if you are trying to maintain weight loss, that you're going to be really intentional about your nutrition long term.

And I'll say, you know, for, you know, every story you may hear about someone who struggled after surgery, there are so many more success stories. And, the vast majority, if not all of my patients who have gone on to get surgery always tell me they wish they had gotten it sooner, because it did change their life so much.

It made everything easier for them. And usually if they've seen me, they've waited 5 or 6 years after I have first introduced the idea to them before they finally feel ready to consider surgery.

And again, they they all just say they wish they had had done it sooner. And I think that's why I chose this field as my profession. I think, like a lot of surgeons and training, clinic was not my favorite place to be.

I wanted to be in the operating room. But when you walk into, bariatric surgeon's office, you see patients every single day who are six weeks, six months, six years out from surgery and able to do things that they just weren't able to do before they had surgery.

So the impact that we can have on patients lives is pretty profound and certainly makes this job very rewarding. Well, thanks so much, Doctor Thompson.

Is there anything you feel like we missed that people should know if they are thinking about bariatric and metabolic surgery? I would say if you're considering bariatric surgery, reach out to your local bariatric surgeon's office.

For patients who may have some concerns or may have had a family member or a friend who had a bad experience, if you're looking to hear from other people, almost every office offer support groups.

And these are often patients who have had bariatric surgery who are sometimes weeks, months or years out from surgery, who get together on a frequent basis to talk about their experiences.

And if you're interested in joining those sessions, I would encourage you to reach out to a bariatric surgeon's office, and try to get involved in those sessions.

Wonderful. Well, thank you so much for joining me.

Kyle Thompson, MD

Is Metabolic And Bariatric Surgery Right for You?