By Marti Webb Slay
According to the CDC, Alabama has 36 counties with obesity prevalence of over 40 percent. Nationwide, obesity affects 110.1 million adults and 14.7 million children, costing approximately $147 billion a year for health care.
Justin Hughes, MD with Eastern Surgical Associates offers robotic bariatric surgery for patients seeking solutions to obesity.
“We will eclipse the 50 percent mark for obesity in the U.S. by 2030,” Hughes said. “It’s a big deal, especially when you think of healthcare costs and how much of a burden obesity is on the healthcare system. For instance, there are 13 different cancers associated with obesity.” Joint problems, sleep apnea, and mental health disorders are also often associated with obesity.
New medications are helping some patients lose weight, but Hughes says surgery can have better outcomes for many. “So far, none of those have the same weight loss, and they don’t have the same control over metabolic associated diseases such as diabetes, hypertension, heart disease, and strokes.”
Ultimately, Hughes sees more overall weight loss for his patients following bariatric surgery as opposed to using medications. “We talk in terms of excess body weight loss rather than overall body weight loss,” he said. “We typically see 50 to 90 percent excess body weight loss with surgery.”
Patients with serious heart disease or lung problems are not good candidates for bariatric surgery, and candidates should be under the age of 75. “Older indications are BMI greater than 40 or greater than 35 with any obesity-associated metabolic problem, such as diabetes, hypertension, hyperlipidemia, fatty liver disease, or obstructive sleep apnea,” Hughes said. “There are newer guidelines now that have dropped those by 5 BMI, especially with uncontrolled diabetes. With Asian patients, they are even considering bariatric surgery for BMI greater than 27.5 because the effects of comorbidities are even higher in that population.
“Usually primary care physicians will refer patients to us for a surgical consultation. We’ll meet with patients to discuss their options. It’s important to tailor the decision of which surgery to pursue, based on the individual patient.
“One type of surgery is restrictive surgery which limits the size of the stomach, such as a lap band or a sleeve gastrectomy. The sleeve takes away the ability of the stomach to hold food and makes it a tube between the esophagus and small intestine. It’s a quick, easy surgery with good recovery.”
Another type of surgery, Roux-en-Y is restrictive and metabolic altering, bypassing parts of the small bowel that control and regulate certain hormones. “You are getting rid of 90 to 95 percent of the stomach and pull up a piece of the small intestine and connect it sort of downstream,” Hughes said. “You will usually see higher weight loss and better control of diabetes, hypertension and high cholesterol. Those can start to resolve even before people start losing weight.
“Another surgery we can use is a combination of the sleeve and Roux-en-Y, a duodenal switch, and it’s become more popular in recent years. Initially these were done with two anastomoses, but more recently they are done with one anastomosis where you just pull a loop up and hook it without cutting it downstream. It seems to work just as well from a weight loss perspective.”
Hughes recommends that patients contact their insurance provider early in the process. “For most insurance plans, we have to show six months of medical weight loss program, or that patients have tried diet and exercise and been addressing the issue before jumping to surgery,” he said. “It’s important for patients to talk to their insurance early to understand the hoops they have to jump through.
“Next the patient does a psychological evaluation, with a third party. One of the hardest things to change is human behavior, so we have to make sure it’s the right time to pursue this.”
A nutritional evaluation is also required. “It’s important to get the patient’s diet moving in that direction,” he said. “It’s hard to move from one type of diet to another post-surgery. You are not able to eat as much and will have to eat smaller meals several times a day. It’s also important to quit smoking before the surgery.”
Hughes stressed that post operative follow-up is important, with appointments two weeks after surgery, every three months for the first year, and then annually. While there are always risks to any surgery, the percentages of major problems with bariatric surgery are in the single digits.
Hughes prefers to do bariatric surgery using robotics rather than doing them laparoscopically. “It’s more precise, and you have better control of the instruments,” he said. “You have better vision, because it has two cameras that give you 3-D vision. Robotics has a shorter recovery than laparoscopic as well.”
“I’d love to see more physicians discussing weight loss with their obese patients. It’s a topic that’s difficult to bring up, but it’s important because of the effect on people’s health and mortality. I think doctors are worried about offending patients, but there’s a considerate way to let people know that you’re worried about them. It’s a doctor’s office, not a place of judgment.”
