Surgeon discusses the ‘obesity pandemic’ and explains why bariatric surgery is the most effective treatment for obesity (he has performed more than 2,000 of those surgeries)
By Chris Motola
Q: You’ve recently joined Trinity Medical WNY. What attracted you to the group?
A: The group here are all fellowship-trained in bariatric and minimally invasive surgery. They just have an excellent program. They also have the Da Vinci robot, which is probably the wave of the future for bariatric surgery.
Q: Why should a patient consider bariatric surgery?
A: Only 1% of patients eligible for bariatric surgery have it annually. Yet, bariatric surgery is the most effective treatment for obesity, in conjunction with proper diet, exercise and behavioral changes. Gut hormone changes after bariatric surgery are a main reason for its effectiveness. Gut hormones that normally act as appetite stimulants tend to decrease after bariatric surgery, reducing hunger and promoting weight loss. Gut hormones that control blood sugars tend to change in favor of better blood sugar control, resulting in improvement of diabetes. There are other gut hormones changes that have their own specific beneficial effects. Non-surgical treatments for obesity generally do not produce these favorable hormone changes. Bariatric surgery also relies on restriction and malabsorption mechanisms to achieve benefits.
Q: Bariatric surgery has been around for a while now. What do the long-term effects of it look like?
A: We think of obesity as a chronic disease, so it needs to be evaluated and treated lifelong. There’s some risk of weight regain. In fact, a little bit of weight regain is considered normal. Abnormal weight regain can happen in up to 10% to 20% of patients. In those situations they need to be reevaluated from a dietary and physical activity standpoint. They may even need another surgery.
Q: Have there been any recent advances in bariatric surgery technique?
A: This may prove to be the decade of robotic minimally invasive bariatric surgery. Only 8% of surgeons performed robotic general surgery in 2012. That figure has soared to 35% in 2018 and this percentage should continue to rise. I recommend that patients interested in bariatric surgery should look for a center that has robotics. The surgery does not have to be done robotically, but a bariatric surgery program with robotics is a good sign that the practice is advanced and up to date with the most skilled surgeons.
Q: Has bariatric surgery gotten safer over the past couple of decades?
A: Now is the best and safest time in history for patients to have bariatric surgery. Almost every bariatric surgeon these days is fellowship trained. That means an entire extra year of training was devoted to mastering bariatric and other minimally invasive surgeries. Also, most bariatric surgery centers are now Accredited Centers of Excellence through MBSAQIP [Metabolic and Bariatric Surgery Quality Improvement Program]. An expert in the field does a site visit at the hospital and office, and a chart review of recent cases. This expert ensures that the program is meeting the safety and quality guidelines set forth by the quality improvement program. Programs must be re-accredited every three years. With fellowship training and program accreditation, safety has come a long way. It is common for many bariatric centers of excellence to report major complication rates below 1%. A recent study in the “Journal of Diabetes, Obesity, and Metabolism” looked at over 66,000 diabetic patients undergoing several major types of laparoscopic operations. The laparoscopic gastric bypass had a lower complication rate than hysterectomy, appendectomy, gallbladder, colon resection, and other commonly performed surgeries.
Q: How has the coronavirus pandemic affected bariatric surgery?
A: As we focus on the coronavirus pandemic, let us not forget about the other pandemic that has been plaguing us much longer and now affects more than one-third of adults in the U.S. — obesity. When the coronavirus hit, elective surgical procedures, including bariatric surgery, were canceled. In response, ASMBS [American Society for Metabolic and Bariatric Surgery] reevaluated how bariatric surgery should be categorized. Given the lifesaving benefits bariatric surgery can have, ASMBS now categorizes bariatric surgery as “medically necessary time sensitive surgery” or “medically necessary non-emergent surgery” and rejects the “elective” category in which bariatric surgery has traditionally been placed. This new terminology will hopefully change how prospective patients, the health care community, our health care system, and society as a whole view bariatric surgery. Perhaps this will get us closer to beating the obesity pandemic.
Q: Besides weight loss does bariatric surgery have any other benefits?
A: Yes — metabolic benefits — and these benefits are sometimes more important than the weight loss. Improvement or resolution is often achieved with diabetes, hypertension, hyperlipidemia and obstructive sleep apnea. The surgery often leads to quality of life improvements such as better mobility, improved sleep, less shortness of breath, relief of back and joint pain and ultimately improved longevity. All new patients go through a comprehensive program at a center of excellence that stresses patient education and evaluation and optimization of diet, exercise, and behavior that continues even after the surgery, so patients get the most benefit from the surgery.
Q: What are the qualifications for bariatric surgery?
A. The basic criteria for bariatric surgery have remained the same for several decades. A BMI of at least 40 or a BMI of at least 35 with a comorbidity such as diabetes, hypertension, hyperlipidemia or sleep apnea.
Q: What are the most common bariatric procedures?
A: All cases these days are done minimally invasively — either laparoscopically or robotically. The sleeve gastrectomy is suitable for most patients. It is the most common weight loss surgery in the world. The gastric bypass is an excellent option for patients with difficult to control diabetes or GERD. Revisional bariatric surgery is now the third most common type of bariatric surgery performed. A sleeve gastrectomy can be converted to a gastric bypass or a BPD [biliopancreatic diversion with duodenal switch]. A lap band can be removed and then converted to anything — a sleeve, a bypass or a BPD. Reflux symptoms [heartburn] and weight gain are two common reasons why revisions are done. The biliopancreatic diversion with duodenal switch is a good option but done less often.
Q: Do you see bariatric surgery ever fitting into more of a preventive care model for obesity?
A: It’s a big risk benefit analysis. It’s been decided by the American Society for Metabolic and Bariatric Surgery that if your BMI is below 35, the benefits probably don’t outweigh the risks. It can be looked at as preventive for comorbidities like diabetes, high blood pressure, high cholesterol, sleep apnea. We sometimes see improvement or even complete resolution of those issues with bariatric surgery and a good chance of them never acquiring them if they don’t already have them.
Lifelines
Name: Mark Cavaretta, M.D.
Position: General and bariatric surgeon at Trinity Medical, WNY Group, affiliated with Sisters of Charity Hospital and Mount Saint Mary’s Hospital
Qualifications: Board-certified general surgeon and fellowship-trained in minimally invasive bariatric and foregut surgery.
Interests: Robotic surgery, endoscopy, and a wide range of emergency and elective general surgery cases.
Hometown: Orchard Park
Affiliations: Trinity Medical Center
Organizations: American College of Surgeons; American Society for Metabolic and Bariatric Surgery; Society of Robotic Surgery; Obesity Medicine Association
Hobbies: Hockey, chess