Kac Para Yarismasi

Arthritis Diet and Exercises

Bariatric Surgery Q&A


– Hello, everyone, and welcome to our Michigan
Medicine live event. I’m Ed Bottomley with the Michigan Medicine
Department of Communication, and today we’ll be
discussing bariatric surgery, what makes someone a good candidate, what to expect before and
after the procedure and more. So let’s meet our experts. Over on the far end, we
have Dr. Nabeel Obeid, a bariatric surgeon, and he’s also leading Michigan Medicine’s
bariatric program in Chelsea. So we’re gonna talk more
about that new location during the course of our chat. In the middle, we have Alex Kennedy. She’s a dietician and
she works with patients before and after surgery to address the nutrition aspect of the program. And next to me, we’re
also pleased to be joined by Christina, one of Dr. Obeid’s patients. Christina had bariatric surgery and she can speak more about the actual patient
experience as well. Just a reminder, you can
submit your questions at any time, even now, for
our panelists to answer during the Q&A portion of today’s chat. Questions can be submitted
by commenting on the video, but please note that if you do comment, your name or your profile name will be visible to others participating. If you prefer a more anonymous option, you can also send a private
message to us via Facebook. If you can’t stay for the whole chat or want to share the
recording with a friend, a video of this chat in its entirety will be on the Facebook page
and it will also be posted to the Michigan Medicine YouTube
channel shortly after that. So let’s get started
with our first question. How do I know if bariatric
surgery is right for me? Can you be too healthy
or not healthy enough for bariatric surgery? Dr. Obeid.
– I think I’ll start that off. I think that question’s best answered from sorta multiple perspectives. From a medical, surgical perspective, there’s certain things
that a provider may want to know more about when
interviewing a patient in their initial consultation, but I would say there are some
relatively fixed guidelines in who qualifies for bariatric surgery, in terms of, is someone
medically fit for surgery? That’s a determination that we make at their initial consultation. So my advice is if
you’re thinking about it, or interested in learning more, easiest thing to do is
just to call our program and we can set you up with
an initial consultation or guide you further. But there are some medical things, whether it be patient’s medical history, types of medications that
they take, previous surgeries, that may determine how well
they may be a candidate for the operation. – Thank you. The next question that we
have moving on from this, how do you determine a
good candidate for surgery? Alex, how would you determine
a good candidate for surgery from a lifestyle, behavior,
dietary standpoint? – So when we’re first
evaluating patients for surgery, there’s a few things that
I look for and evaluate, and the first thing, a
willingness to change. So there’s a lot that goes on. It’s not just surgery alone. There’s a lot of lifestyle,
social things that change and so patients have to be willing to change things in their lives. So that’s the first thing. And then also I’m evaluating
for a baseline knowledge to see, have people tried
weight loss things in the past? Some people come in, they know
the calories in everything, or they’ve done Weight Watchers, and they know this has eight
points and this is a carb and this is a fat. So I try to evaluate and
see where the patient is at. So that’s pretty much
what I look for initially. – Dr. Obeid, you touched on this a tad. How do you determine a
good candidate for surgery from a surgical perspective? – Well, there are certain conditions that may make the physical
act of performing surgery very risky or basically not
an option in certain patients. If someone has had previous
stomach surgery, for instance, that may alter the types
of bariatric procedures that may even be an option
for that particular patient. Very severe medical
conditions like heart failure or advanced kidney disease
can pose certain challenges. in taking care of patients, but having said that, we treat
patients of all the spectrum of medical complexity
and previous operations. So, again, it really comes down
to a detailed history taking and examination of the
patient to determine what those factors might be that helps us make that ultimate decision. – Sure, indeed. The next question that we have, does Type II diabetes
make my surgery riskier? – I would say the answer to that is no. About probably 40 to 50% of
our patients are diabetics, if not potentially more, and so this is a very common condition that’s associated with obesity. Traditionally, obesity and
diabetes are risk factors for certain things like wound healing, but because we do these
procedures laparoscopically, which means with small incisions
and the camera technique, there really aren’t
many wound complications related to this operation, and because most of our
patients are diabetics, we’ve been able to demonstrate that we can do this operation safely. – Thank you for that. Will I be able to stop
taking my diabetes medicine after surgery? – That’s a great question. And we can go down the panel to get different people’s takes on it. So in general, bariatric surgery, which is a metabolic operation, so one thing I like to
point out is it’s much more than just a weight loss surgery. I talk to my patients about the fact that there are significant
metabolic changes that occur with this operation, and
so I actually don’t like to refer to it as a weight loss surgery. One of those conditions being diabetes, in that it significantly
improves after the surgery, and some of these conditions,
diabetes, sleep apnea, blood pressure issues,
cholesterol, reflux disease, many of them get better or
improve to a certain extent independent of the patient’s weight loss, meaning that they may see results and improvement of their health even before they’ve reached
their maximal weight loss. And diabetes is no exception to that. In fact, we do have patients who routinely leave the
hospital with potentially up to half of their
previous dose of medications going into surgery and
then leaving the hospital with half to maybe even
none of the medications that they were taking before in order to control their blood glucose. So it does have dramatic effects. Now that’s not the same for every patient. So to answer your original question, is everyone gonna expect to be completely off diabetes medications? Not necessarily, but you can expect that you’ll have a significant improvement in your diabetes control
and most likely a reduction in the dosage of the
medications that you take. – Great, anything to add to that, Alex? – No, I definitely see that. When I see patients at
two weeks after surgery, a lot of them are significantly reduced in their medications and
they’re already feeling better. They are all on a pre-surgical diet, which I think also helps
with the insulin levels and all of that, but it’s pretty exciting. – Christina, perhaps we could get your perspective on this, too. – So, actually, I was pre-diabetic. So I hadn’t taken any insulin. I wasn’t worrying about that, but once I had the
surgery, they tested my A1C and it went from, I
believe I was at a six, and now I’m at like a 4.9. So it really changed the whole game. So it was nice to no longer
have to worry about that. – Oh, indeed, indeed. – I actually had a question
that I just thought about that we get asked a lot, kind of related. A lot of patients will say or ask, if I can lose weight on my own, why would I go through surgery? And I think the point that you said about it being a
metabolic surgery is huge. So I think with traditional dieting and trying to lose weight, a lot of people are up against hunger. They’re battling that constantly, or they just can’t feel
full, or things like that. So not only does surgery provide some sort of built-in portion control, but it also provides these
amazing metabolic benefits of just the insulin regulation and also hunger hormone regulation. So feeling full, not
craving certain foods, those kinds of things, is
a huge benefit of surgery. – Thank you for that. The next question that we have, how soon can health conditions
improve after surgery? – So as I alluded to, it
can be as soon as a few days following the procedure in the case of things
like glucose control. Some things take a little
bit longer, a few weeks, maybe even months or
years until they manifest. Very common conditions that
improve relatively quickly after surgery include, again, diabetes. Obstructive sleep apnea is a big one, and it’s a common one among our patients. Many of them find that
their settings on their CPAP go down significantly within
a few weeks of surgery. They can feel the difference. They’re getting a better night’s sleep, feeling energized and
rested when they wake up in the morning. And, again, that can be
independent of their weight loss. So it’s something that’s seen relatively quickly after surgery. – And the next question that we have, this is something that
you touched on just a bit. How is sleep and weight loss related? – Sleep and weight loss? – Yeah. – So, again, there are multiple factors associated with that. Obstructive sleep apnea is the main one, which is a condition
that is not just related to the anatomy of the neck and the airway, although it’s oftentimes
felt to be mostly related to having a large, heavy neck
that obstructs the airway, but a lot of good research has shown that it’s much more than that, and there’s a connection with the brain, and neural hormonal pathways
that help to regulate that, which is actually why we think that that sort of condition
improves quickly after surgery, despite the fact that
the anatomy of the neck hasn’t changed all that much. And so there are some
more physiologic issues that can affect that, that, frankly, aren’t
completely sorted out in the medical literature to this point. But having said that,
patients oftentimes feel that their sleep patterns,
their breathing patterns, they’re not abruptly stopping breathing in the middle of the night,
something called apnea, and so, again, they feel much more rested and feel like they’re
energized for the day soon after the surgery. – Sure, anything to add to that? – Yeah, I think of it
from the food perspective. So when people wake up
and they’re super tired, they’re usually reaching for, you know, they make poor food choices, and a lot of energy drinks
or sugary coffee drinks to keep them awake, and
so throughout the day, maybe not making the
healthiest food option can then lead to weight
gain, which starts this cycle of then affecting the sleep habits and it’s this cycle that happens. – I was on a CPAP when I had the surgery and then after every
10 pounds I would lose, I’d try a night without it,
and my poor husband used to say that it sounded like I was
sucking the paint off the wall (laughing) before I had my CPAP, ’cause
I was snoring so badly. So I had my surgery in March. By June, I was completely off my CPAP. I sleep a good solid six
to eight hours a day, depending on how tired I am
or if I’ve gone to the gym. I always feel very well rested and the only time I have
a hard time sleeping or breathing at night is if I’m sick. And it’s the most wonderful
feeling to be able to sleep without that Snuffleufagus mask on you. So it was really, truly a great moment when I realized I didn’t
need that CPAP anymore. – That’s great. Thank you for that. The next question I have,
do I have to go on a diet before I get surgery? – Yes, (laughs) yes, there
is no way around that. The diet, most people
call it a liquid diet, but there are a few things you
can chew on the liquid diet. Typically, it’s two weeks long, sometimes up to three or four weeks, depending on medical history, and that’s determined by the
surgeon, how long it will be. But that’s what we’re here for. We follow patients pretty thoroughly and they’ll take a class and learn all about this liquid diet, primarily made of protein shakes, but the purpose of it is to
shrink the liver before surgery. It makes surgery a little bit safer and then also help lose
a little bit of weight before surgery as well. – Great, great. – Do you have any comments
about the pre-surgical diet? (laughing) – It’s not terrible. I mean, honestly, it’s just
something to get used to and you’re already invested in making this huge life change post-op. You have to put that time in pre-op. So it’s getting you used to
what your meals will look like or how to get that discipline. The shakes aren’t terrible. I mean, I certainly
wouldn’t want to have that as my first choice every day, but there’s a great chicken soup option. You get to celebrate at
night with some veggies if you’re going crazy. But it wasn’t awful and
it’s just a really great way to ease yourself into this
huge thing you’re about to do. – I’ll add just one more thing to that. So Alex had alluded to
the purpose of the diet, aside from getting you in
the rhythm into surgery and then to follow that post-op diet, the reason we do it pre-operatively, in addition to shrinking the liver, which helps dramatically
for the technical aspects of the surgical procedure,
we have to be able to lift the liver up to be able to see and work on the stomach, and if patients have not been
on that pre-operative diet, the livers can be very
heavy and very difficult to move out of the way. And so it makes the surgery
a little bit more risky and less straightforward
if that hasn’t been done. And just to add to that, there have been some really good studies to show that doing that
pre-operative diet, which is, again, usually two weeks, but sometimes up to four weeks, depending on patient factors,
has been shown to decrease the chance of complications
related to the surgery. So there are multiple
good reasons to recommend and mandate that patients do
this leading up to the surgery. – Yeah, indeed. Thank you for all those answers on that, all those perspectives. The next question we have,
will I have to diet or exercise after the procedure, and how long for? – Forever. So bariatric surgery is not
a quick fix for weight loss. Obviously, it helps jump
start it quite a bit for a lot of people, and there’s what we
call a honeymoon phase, where people really feel
the hormonal effects and the fullness cues, and
everyone’s a little different, but typically that kinda wears off and people really have to start focusing on what they’re eating,
how much they’re eating, and exercise, just as
you would before surgery. So it is definitely a lifelong commitment to not only lose weight, but then keep it off in the long term. – Do you have any comments? (laughs) I’m sure you do. – Yes, I wasn’t a real gym
rat or anything before, clearly not working out
as much as I should, but now I go to the gym
three to four times a week. I go to a Crossfit class. I’m not a Crossfitter, but it’s activity, and I know when I don’t
do it, I don’t feel well. You can see the scale
kinda move a couple pounds and it’s something that
I know I will have to do for the rest of my life. It’s ridiculous, and I
know that people listening are saying I’m full of garbage, but I swear, you get addicted
to that good feeling, those endorphins, that
way that it makes you feel throughout the course of the day, and it becomes a part of your life, and it’s so much better. I’d rather reach for my gym bag than reach for candy or pizza. So, yes, it’s something I know I will do for the rest of my life, and
I’m pretty cool with that. – The next question, if I have surgery and don’t follow the diet
guidelines, what will happen? Will I just gain weight,
or will I get sick? – Potentially both. Initially, after sometimes
people will try to move too quickly throughout the diet. I mean, as the stomach gets
healing, it’s very much liquids, and then pureed and soft foods, and some people will move too quickly and they’ll get sick. Their stomach can’t
tolerate it at that time. But long term most people can
tolerate pretty much anything without really getting sick. I think rare cases people will become ill after eating certain foods, but have you experienced any foods that– – I can’t eat asparagus
anymore for some reason. (laughing) – Yeah, it’s always a
random food for some people. – It’s something weird. – Like lettuce tends to be
a big one for some reason or really dry grilled chicken
breast or things like that. But, yeah, it’s different for everybody, but I think definitely using us a resource to help people through the process. – Yeah, a couple things to add to that. So early on after surgery
and the healing process, certainly patients can
feel like swallowing foods and particularly certain
foods feels quite different than it was before
surgery, and very early on, even sips of water can feel uncomfortable or odd to the patient, and that’s all normal. It’s part of the healing process. The stomach is obviously
integral to the swallowing and the GI tract process
for digestion of foods, and, of course, when you
operate on the stomach, you feel those effects. But it’s certainly not
a long-lasting effect in terms of the difficulties
or the sensations with the swallowing. I will say with one
procedure in particular, the Roux-en-Y gastric bypass, sometimes just referred to as the bypass, there is something
called dumping syndrome, which can make you feel
ill with certain foods, generally high concentrated
carbohydrate sweets can make you flushed and sort of ill, and so patients quickly learn
to stay away from those foods because it can have a dramatic
side effect in that regard. But, yeah, and then just
to comment on the asparagus and other things, it’s
very common for patients to have a complete change
in their taste buds, what’s appetizing to them, at least for certain foods in particular, and most patients can identify
that one or two things that they used to enjoy and they just don’t have
the appetite for anymore, or something that they used
to not really find appealing is now something that they enjoy. So not really clear in
terms of the science behind that change, but
it’s a common observation. – That’s fascinating. Next question we have up. I don’t like to slash
don’t know how to cook. Can I stick to the nutrition guidelines if I mostly eat out or eat takeout? – That was your question. (laughing) – I believe that it doesn’t
matter if you don’t know how and you don’t want to, you
really need to learn how to cook. You’re about to make a huge
investment in your life and for you to say I’m not going to or I don’t want to learn how to cook, you’re not gonna be successful. You cannot go to a McDonald’s and be like, I’m just gonna order a chicken breast. It’s too triggering. You’re gonna be like,
nope, I’m gonna have a fry. I’m gonna have six fries. I’m gonna have 40 fries
and now I’ve had a large. It doesn’t make sense. You are putting yourself through a lot. You’re doing a lot of
pre-work, a lot of post-work. Your body’s going through a huge change. Learn how to cook. It’s not difficult. You can slap some chicken
breasts in the oven at 325 for 45 minutes, Bob’s
your uncle, there you go. You’ve got food. There’s YouTube. There’s Food Network. There’s no reason that you
can’t learn how to cook. So for me personally, I
would say absolutely not. You cannot be successful if
you’re not gonna take care of yourself in your home everyday and learn how to do that. – And I completely agree with that. I do, like 100%, but I do
think now we live in a time where a lot of people are
focusing on health quite a bit and I think restaurants
are taking note, too. So I do think there are
several options at restaurants, but what I like to do is teach people to be knowledgeable of nutrition so that they can go
anywhere and figure out what they can order and
still be on the plan. So it’s not like you have
surgery, your life ends, you can never go out, you can’t socialize. There are options places, but
just knowing what to ask for, how to ask for it. So that’s the perspective I come from. – Agreed. I’m not like, I don’t hibernate. (laughing) I don’t hibernate. It’s not like I never
go out and do anything, but I think when people are
thinking of convenience, you have to learn. You’ve gotta put the time in. You’re making yourself a priority. Make it a bigger priority. Cooking is one of them. – And on that note, too,
a lot of people think that healthy food has to
taste bland or like air. It doesn’t. There are so many amazing
websites and recipes where you can use herbs and spices and make healthy food taste really good. And, again, that’s kind
of what we’re here for, to help with that. It doesn’t have to be gross. Just like chicken slapped (mumbles). (laughing) I was picturing this. – It’s just a thought. – I know, I know it is. – I appreciate those answers a lot. Next question, can I drink
alcohol after having surgery? – Well, I’ll say, just
from a purely surgery slash anesthesia standpoint,
we certainly wanna avoid that in the early post-operative period, but taking that a step further,
it’s really not recommended to engage in ingestion of alcohol for probably at least the first year. There are some interesting
medical literature that one of the unintended
consequences of bariatric surgery for some people who might
be at risk is dependence, and so we take that very seriously, and we don’t want patients
to fall into a certain trap or develop these poor
coping mechanisms or habits that end up becoming a serious problem for their mental and physical
wellbeing down the road. So that’s a pretty serious recommendation that we have in our program. I’d be curious to see
what other people think. – Yeah, in our initial evaluations, we always talk about alcohol. I mean, A, from just a
nutrition standpoint, it’s empty calories. It hits the bloodstream really fast, so people often become very cheap dates. Before surgery, they can kick
back three glasses of wine and after, they’re a couple
sips in and they’re feeling it, which, then, I think relates
back to the dependences. When people turn to food
for any sort of coping, they can then turn to alcohol, and it hits them pretty quickly. But, yeah, we just say
to stay away forever, as long as you can. On special occasions, okay, but really trying to be mindful of that. – I’ve recently had an issue with this and it’s not great. I found myself through
the holidays and after, with some changes going
on, with my husband’s work, and I just think I celebrated too much through the holidays and
sorta kept that train rolling, and I recognized rather quickly along with the help of my therapist that I was starting to
swap out my addictions. ‘Cause, you know, obese,
I’m a food addict. So now, new coping. So I have stopped drinking completely. I haven’t had a drink in about 45 days. It’s hard to admit that, but it happens, and without the help of
my family or my therapist, I would probably be injecting
heroin in my eyeballs, but it’s something to be really aware of, and as long as you’re paying attention, and you’re seeking the help
and you’re talking about it and you’re getting it out. You’ll get there. – And I think now that we know that it can happen after surgery, we have resources and
people we can refer to if patients ever are
thinking I think I’m drinking a little more than I used to, so we always recommend,
talk to us about it. It’s not something to be ashamed of. – Yeah, absolutely, absolutely. Thank you for those answers. Next question we have up, can I eat the same day I have surgery? (laughing) – I guess if you wanted to
get very sick, you could, but, no, we do not recommend that. Usually day one is pretty
much just focusing on fluids, just trying to prevent
dehydration the first day, and then once you’re home,
we educate all patients as far as the diet transition. So like I mentioned earlier,
it’s liquids for a while, protein shakes primarily,
and then transitioning into pureed foods and soft foods, and then finally more regular type foods. There are all different time points, depending on surgery, but
no, we don’t recommend eating right after surgery. (laughs) – Nor would you want to. Let me just throw that out there. You have no desire. (laughs) – Yeah, I think most people even struggle just trying to get the fluids in, just the way that they’re feeling. – Yeah.
– Yeah. – The next question we have up is with regards to energy levels. Will my energy levels
change after surgery? – In my experience, most
patients find that it does. Again, how fast that
happens varies for people, but I think for a number
of reasons, it will. With the weight loss that’s
innate to the surgery, you will feel like you have more energy, can get around a little bit easier, but, again, in addition to improvement of other medical problems that will increase your energy level, in addition to proper nutrition and following the dietary counseling. – Yeah, I think when I see
patients, it kind of depends. Either at the two-week visit, they’re bouncing off the walls. They don’t know what to
do with all their energy, or they’re kind of sluggish,
and then by two months, then they’re bouncing off the walls. But, yeah, a lot of times,
it depends on sleep, too. If you’re losing weight, sleep apnea, all that relates to how the person. Everyone’s different, but
usually by two months, everyone’s feeling great. – Okay, so we have a question
just in through Facebook. We’ve been asked, when
does being overweight signal a need for bariatric surgery? Do you have to have a
condition like diabetes before considering surgery? – That’s a great question. I’ll answer it in two ways. The first is the strict guidelines for who qualifies for bariatric surgery, and the second is really
what the National Society’s trying to move towards, but just so everyone’s aware,
most insurance companies will abide by the National
Institute of Health consensus guideline, which
is dating back to 1991, and for that, it’s a BMI of 35 or more, if you have usually one
or two obesity related medical problems, or if
your BMI is 40 or above, regardless of medical problems. And so those are the typical criteria for meeting eligibility
for bariatric surgery. Now to segue into that
second part of the answer, we’ve recognized that
patients with lower BMIs, in that 30 to 35 range,
actually can benefit greatly from, again, metabolic bariatric surgery, not just weight loss surgery, and there are some really good studies, both nationally and internationally, looking at patients with a
BMI of 30 to 35 with diabetes, and showing that they can
actually reach diabetes remission in that group. So it’s actually starting
to become a topic of conversation, somewhat
still controversial, but there’s more energy and
thought going into that, in terms of potentially intervening sooner in that BMI range. – I have a follow-up to that. What are some of the
obesity-related comorbidities that would qualify?
– Right, right. So the traditional
common medical conditions would be blood pressure,
otherwise known as hypertension, cholesterol issues,
obstructive sleep apnea, which we’ve talked a lot about, gastroesophageal reflux
disease, or heartburn, reflux, arthritis, very common
musculoskeletal conditions related to stress on the
joints, the hips and the knees. And then there’s also mental
health related disorders. Anxiety and depression are very prevalent in
our patient population. So all these things are
potential qualifiers for bariatric surgery,
and more importantly, things that can drastically
improve following the operation. – Thank you for that. Next question that we have up, what kind of tests can I expect to take to get approved for surgery? – So that will vary based
on the individual patient because no patient is
the same as the next. Everyone is individualized, and that’s how we treat
patients in our program. We look to them as their own individual and customize their care accordingly. Certain conditions or medical history may warrant further work-up. Just to give you a broad overview
of the program in general, every single patient requires
an initial consultation with our program, which is done
in terms of several domains, one being a thorough medical evaluation done by our physician assistants, and, of course, a thorough
dietary evaluation and counseling done by our dieticians, as well as a comprehensive
psychological evaluation. So all three of those are core tenets to the initial evaluations. Beyond that, a combination
of recommendations based on those initial evaluations and, after meeting with the surgeon, we’ll determine what
additional tests are required. Some are medically necessary. For instance, if someone has
significant heart disease, coronary artery disease, maybe they have previous
stents in their heart from a heart attack in the past, we many want them to get a
stress test or an echocardiogram or speak with their
cardiologist to make sure that they’re safe to undergo surgery. Patients get screened for sleep apnea. If they test positive for that, then we will recommend that
they undergo sleep testing. Some patients who have
reflux type symptoms may require an endoscopy,
an upper endoscopy, to further evaluate that. So it sorta depends, and
unfortunately, aside from what we deem as definitely necessary, some insurances have their
own requirements as well. So part of that, the
answer to your question really depends on the patient’s insurance. – The next question that we have up, Dr. Obeid, can you describe
the different kinds of bariatric surgery available
at Michigan Medicine? – Sure, sure. So the two main what we call
primary bariatric procedures, meaning that you’ve never have
previous bariatric surgery that we offer are the sleeve gastrectomy and the Roux-en-Y gastric bypass. Both of those are done laparoscopically, meaning with the small incisions
and the camera technique. We’ll start with the sleeve gastrectomy, which is the most common
bariatric procedure performed in America today. It’s about 60 to 70% of
all bariatric procedures done across the country. What we do with a sleeve gastrectomy is, in essence, we are trimming
down the size of the stomach and leaving a long sort
of tubularized stomach without re-routing the
gastrointestinal tract, and the way we do that is during surgery, we have the anesthesiologist pass a sizer, which is basically a tube
that is a particular diameter so we know how thin or wide
to be making the stomach tube. And by doing that, we
remove the excluded part of the stomach. We remove it out of the body
and what you’re left with is the food tube called the esophagus, going down into the sleeve stomach, which is this tubularized stomach, and then into the first
part of the small intestine. So, again, the anatomy of
the GI tract is not altered in that regard, but the size of the
stomach is made smaller, and there are multiple
reasons for why that works. Part of it is a mechanical reason, sort of oversimplifying it. You make your stomach smaller so you can accommodate less food and you feel full with less food, but there’s really a more eloquent, dramatic component to it, which is a neurohormonal component. Part of the stomach that gets removed is the part of the stomach
that is involved with hormones of the gut related to satiety
or feeling full, hunger, and it’s the part of the stomach that communicates with the brain, and so there’s a pretty
in-depth hormonal component to this as well. The Roux-en-Y gastric bypass,
again, otherwise known as the gastric bypass or bypass, is a procedure that’s
been around for decades, and a procedure that works quite well. In contrast to the sleeve,
it does alter the anatomy of the GI tract, so we
make the stomach smaller, called a gastric pouch,
and then we re-route, we divide the small intestine
and bring up a portion of that intestine to attach
to that gastric pouch, and then re-configure and connect things back together downstream, and by doing that, it allows for a lot of that
hormonal effects as well. There are some good studies that show that the food bypassing that
first part of the intestine has a dramatic effect
on not only weight loss, but glucose control, so that’s where improvements
in diabetes can play a role and other factors. Now both procedures have
their own pros and cons, and that’s a detailed
discussion that you’ll have with your surgeon when you meet with them, and depending on patient’s
medical comorbidities, meaning medical conditions, as well as any medications
they might be taking, it can affect or sway the recommendation for one versus the other. And so that’s a fair bit of information, but it’s a good overview of what the different procedures are. – No, that’s great. Yeah, that’s great. – One thing I’ll add to that, and maybe Alex can comment as well, is all patients require
nutrition supplementation following bariatric surgery, and the regimens differ
slightly based on the procedure that you undergo, partly
because with the gastric bypass, part of the nutrients that
we ingest are absorbed in different parts of the GI tract, and when you re-route the GI tract, it can affect the absorption
of some of those vitamins and micronutrients, et cetera, and so the regimen is
a little bit different based on the procedure. – Yeah, so, and you’ll
learn more about that. For bypass, like he said, vitamins and mineral supplementation
is required for life, so that’s not a temporary thing. Because, A, the stomach
is a little bit smaller. There’s less enzymes to break down food. Not all vitamins and minerals
are absorbed very well. So, actually, her alarm
just went off on her phone to take her calcium. – Yep. (laughing) I’ll do that right after. – Perfect timing for a Facebook live. The next question that we have, will gastric sleeve cause heartburn? – So that is a great question and something that is still,
frankly, under investigation. There are some studies
that show that it can cause or worsen heartburn, and
so for patients who have some element of significant heartburn when they come to see us, those patients may get
further work-up to determine if they truly have heartburn
and what the severity of it is and there are some subtle
things that we look at in terms of there’s a
sphincter at the bottom of the esophagus that is
related to reflux disease, and how that works or doesn’t work, and that may sway our
recommendation against the sleeve towards the gastric bypass. But, again, I wanna
avoid a blanket statement because for actually most
patients after a sleeve, their reflux may actually improve. Part of it has to do with the weight loss that comes with the procedure. As you lose weight, the pressure
in your abdomen goes down and so there’s less promotion of heartburn with stuff refluxing from
the abdomen into the chest. And so for a lot of
patients, it’ll improve, but we do take significant
reflux seriously and we probably would work them up to get a better understanding
and then determine what the best procedure
choice for them is. – Alex, anything to add? – Yeah, some patients do notice
a little bit of heartburn happening after sleeve in particular, when they never had it before surgery, and oftentimes the behavior’s
around what they’re eating. So carbonation, so any
beverages with bubbles, even if it’s a sparkling water or pop, sometimes can increase the pressure and push that acid upwards. That tends to be a big one, or sometimes, weirdly enough,
drinking through a straw. Sometimes people take in too much air. But then usually once
people stop drinking bubbles or with a straw, it tends, or I’ve also seen it with
some people, chewing gum, if they chew gum with their mouth open, they’ll take in a lot of air. It sounds very weird, but
sometimes that can happen as well. – The next question, how
long can I expect to wait between my clinic visit
and getting the surgery? How do I plan for my procedure? So, again, that’s gonna
vary from person to person, but as a sort of general rule,
every insurance will require a certain amount of time that you undergo what’s called a medically
supervised weight loss program, which are monthly visits, and they’re consecutive monthly visits. Some patients have that
requirement waived. Some patients have that requirement, and it can range anywhere
from three to 12 months, again, depending on the insurance. We work closely with the
patients, their primary providers, as well as insurance carriers to stay ahead of that timeline so that there’s no period of time where they’re just sitting
around and waiting. So we try to expedite
everything as much as we can, but we also don’t wanna minimize
that pre-operative period where it’s important for patients to get all of their
education and counseling and to really understand
their lifelong commitment going into the surgery. – Sure, thank you for that. – A question kind of
piggybacking off of this, a lot of patients ask if
they have to lose weight before surgery, if
there’s some requirement, and, again, that comes down to insurance. Some people have to lose
10% of their body weight, for instance, or they
can’t gain weight at all from their initial evaluation. Again, comes down to insurance. I will say from our perspective, I particularly like to see
a little bit of weight loss, nothing significant,
even just maintenance. I get a little alarmed when
weight increases quickly. Some people participate in
what we call food funerals, so they’ll be like, oh my God,
I can never eat this again and then they just kind of
eat everything that they can and their weight significantly increases. So sometimes we will hold
up patients a little bit from that just because we wanna set you up for success afterwards. So that can extend the time between initial and surgery for sure. – And patients are
obviously gonna be curious in terms of the timeline and the process through the program. We try to consolidate
things as much as possible. For instance, sometimes we’ll do the initial medical
evaluation on the same day as the dietary evaluation. The psych evaluation
is a longer evaluation. It’s, I think, a three-hour
comprehensive evaluation, so many times that’s
done on a different day. But we try to keep those things in mind so that we minimize patient
travel and inconvenience and things like that. So we’ve really streamlined our process to try to accommodate patients and make it a relatively
straightforward process through the journey. Christina, I don’t know
if you have any comments. – I was sort of fast-tracked. I did my initial evaluation
at the end of January in 2018. My surgery was March 20th, but
I also had a really high BMI and I’d already done my sleep study. I already had my CPAP. So I didn’t really have any other issues and so actually because
somebody had canceled on your schedule, I was able to get my surgery
scheduled pretty quickly. So I know that that’s not
typical, so I wouldn’t go by me, but that is how it worked for me. – I think a typical
patient probably would be anywhere between six months to a year from the initial evaluation to when surgery would actually happen. So it can be a potentially
longer process for some people. I would say most people
it’s a little bit longer. – I was special.
(laughing) – Yeah, you are special. Very, that’s why you’re here. – Well, the next question for
Dr. Obeid, is surgery painful? – Well, no surgery’s gonna be pain-free. So I have to set that expectation, but as opposed to traditional surgery, this is small incision
surgery, laparoscopic surgery, which has significant
advantages in terms of recovery, chances of wound related
complications, and pain control. With a traditional cut,
with traditional surgery, it can be quite painful, and laparoscopic surgery
really has that advantage. Now most patients, of course, we do things
like give pain medication, a high dose of Tylenol and
ibuprofen type medications, depending on the patient, around the time of the surgery itself and we give a lot of numbing medication so that they come out of
surgery relatively comfortable. But in my experience, the first 12 hours until the following morning
can be rather uncomfortable. Most patients describe an upper abdominal pressure slash pain. That may have to do with the
dissection that’s required with surgery of the stomach
along the diaphragm. And by the next morning, that pain is significantly improved. Nausea can also be an issue in the early post-operative
period, but for most patients, we get them through it
without much of a problem, and, frankly, I hear both. I hear that was a little bit more involved than I was expecting, and a lot of patients saying
that wasn’t nearly as bad as I was expecting. But we try to set expectations. No one’s gonna be completely pain-free, but in general, I would
think of it similar to a routine gall bladder surgery. It’s a similar type of procedure,
small incision, cameras. We do a lot of numbing
medication to make the patient feel relatively comfortable. The real expert in this
is gonna be Christina. – Yeah, I was gonna say. – Honestly, for me, it wasn’t bad. I had had my gall bladder out previously. I had an easier recovery from this surgery than I did the gall bladder. I think part of that was due
to the pain management plan which was put into place
and discussed, I think, at every single visit I had,
whether it be with Dr. Obeid, the NP, or with dieticians. This is what the plan is and this is what you’re gonna go home with and this is what you need to be ready for, and you’re gonna have pain. This is surgery. So I already knew that I was
gonna have a limited amount of pain medication in terms of a narcotic and I also knew that the
goal was from the minute they wheeled me into
my room post-op, walk. Walk, walk, walk, walk, walk, and I did. I think I lapped that
floor about 400 times because I knew, as much
as it was uncomfortable, that the more I walked,
the better I would feel, the sooner I would feel that go away. The most painful part of
the surgery, I think for me, was the gas, ’cause they
fill you up with gas, and it kinda gets trapped
up in your shoulders. So you just kinda have to
roll around on each side every 20 minutes and sorta move it around, but then again, walk,
walk, walk, walk, walk, and then you get to go home. – That’s right. – But, honestly, that gas part
was the worst part for me. – Thank you for that. So we’re heading into
the final 10 minutes. We still have a few questions to get. I know.
– That went really fast. – So we’re gonna get
through these questions. The next one for Dr. Obeid, what’s the recovery process like? How much work will I miss
with bariatric surgery? – Yeah, that’s a common
thing that we discuss at the surgeon’s visit. So I would say it’s a good
bet to be off from work for about two weeks, okay? But your restrictions go beyond that. So I generally counsel my patients that for the first month after surgery, that I would advise
that they don’t do a lot of heavy lifting, which I usually
define as 10 to 15 pounds. Because we want the wounds and
everything to heal properly, and when you’re doing a lot
of lifting or straining, that can affect wound healing. And so that is one of
the main restrictions for post-op recovery,
of course, in addition to their dietary progression, but in terms of missing time from work, assuming that it’s a desk job or something that’s not labor intensive, then I would say two weeks
is probably a good range. Some people may feel
ready earlier than that. Some people may need longer than that, but that’s sort of an average. But certainly the first week,
most people are not feeling up to doing a whole lot
other than just resting and recovering at home. So that’s the general advice
that I guide patients with. Again, Christina. – I have a desk job. So I took three weeks off because I coulda gone
back after the second, but I was going onto not solid foods, but the softer foods,
and that wasn’t something I wanted to test at work. I thought, well, let’s just
hang out and do that at home. But I was able to do some work from home, but, yeah, three weeks, back ready to go. – Okay, next question we
have for Alex and Christina, how long will it take to settle
at my new and actual weight? What if I don’t lose all the
weight I expected to lose? – That’s a good question. So this is an annoying
answer, but it depends. So people with more weight
to lose are going to lose a bigger amount within the first year. So we try to give patients
a projected weight, based on your height and your weight and your comorbidities,
where do we expect you to be after a year. A man who’s 6’4″ who
weighs more than a woman is going to lose weight
a little bit faster. So a lot of people like to
go on Facebook or YouTube and they’re like, oh my gosh,
how has she lost 100 pounds in three months and I’ve only lost this? So we don’t recommend doing that. So everyone’s different as
far as settling at a weight, traditionally in the beginning,
weight loss is very quick, but plateaus are very, very normal as with any other plan. So people will settle a couple times and then get to a weight. It can happen, but I think
with an increase in exercise or sometimes reevaluating
what exactly is going in as far as calories go. Sometimes people can get past that, but sometimes your body’s
just happy with where it’s at, and usually at that
time, I like to focus on, how are you feeling? People will focus so much on the scale and they don’t realize
they just walked a 10K or they’re on the ground
with their grandkids or things like that they’re
not really thinking about, and that’s a huge, exciting thing. – [Dr. Obeid] Or they’re
off some medication. – Yeah, they’re off medications. They’re not on their CPAP. There are so many other incredible things besides the number. – Sure. Christina, how did you
discuss surgery with family, friends, colleagues? – My husband, I asked him
this question last night. He said you actually just came up to me and said I’m gonna do this surgery, which I don’t think is true, but anyway, I talked to
everybody and just said, listen, you guys have known me my whole life. I have struggled, I have yo-yoed
and I am tired and I hurt. So this is what I’m gonna do and it’s gonna be me being super selfish for the next year to the rest of my life, and I need to focus on me, and pretty much everybody got on board. I didn’t have anybody who was against it. Everybody just had questions
and I’m very lucky. They were all really supportive. So it was just, this is what I’m gonna do. My best friend in particular
was super concerned, so I sent her to the
website to see the videos and understand, and I think
that that’s a terrific resource when you’re talking about it with people who just don’t understand,
and after she watched that, she was like, I get it, I’m on board. So it was pretty quick and
I’m not asking permission. I’m telling you I’m going to do this. – That’s fantastic and as a patient, what was the most surprising outcome and possibly the most
challenging part of the process? – I will tell you the
most challenging part is the mental game, and anybody who tell you
that this is a quick fix, an easy way out, they have no idea. Most of us, all of us
watching, are food addicts. We have addictive personalities
and there’s a reason and nine times out of 10,
it’s because we’re too busy taking care of everybody else, making sure everybody else is okay, doing everything for everyone, and we stop taking care of ourselves. And it’s really easy to
bury stuff with food. So for us to have this
surgery, we have to talk about the triggers and the
reasons why we’re this way and how this is our coping mechanism. So the mind game has been rough. I’ve always had a therapist. I was seeing her once a week for forever, and sometime around June,
it was like holy cow, here comes all of the feelings, and you start feeling all
your feelings all at one time, and you have nothing to do. You cannot eat. What do you do? It’s hard. So that’s been the surprising part, but it’s also been the most freeing part because you’re dealing with the stuff that’s really been there
for a really long time. The thing that’s been
pretty much the coolest and surprising is finding
out you have muscles in places that you didn’t know existed. (laughing) My husband hugging me and
going what’s that on your back? Oh my gosh, these are muscles. So it’s been pretty fun. (laughs) – Great, that’s great. The next question I have is for Alex. When can I get pregnant
after bariatric surgery and will the baby be healthy? – Yeah, great question. We actually see so many women
who want weight loss surgery because with weight loss, women
actually become more fertile and so it helps women get pregnant. So we do say for the
first year after surgery, not to get pregnant
because you’re still trying to provide your own body
with the proper nutrition, but after surgery, yes,
women can definitely become pregnant, and really,
actually, women don’t need as many calories as
they think that they do. The eating for two myth isn’t really true. It’s really only like
300 to 500 extra calories in the third trimester. But we work with a lot of patients who we try to sneak in higher
calorie healthier options to get them to that level
after, but yeah, definitely. – Fantastic, thank you. What if I need to have plastic surgery? Does insurance pay for plastic
surgery after weight loss? – So sometimes insurance, again, depending on the plan, will. Our advice is, well, first of
all, from our plastic surgeons is they want to make sure
that weight is stable for at least a year. So they don’t wanna
remove skin from somewhere if someone’s going to
continue losing weight or if they might potentially gain. So I think that’s one of the criteria from our plastic surgeon perspective. And then as far as insurance goes, I believe they will only cover it if it is a medical
necessity, not for vanity, and I think only around the
abdomen, and if it’s rubbing. So what we recommend is if you have lost
successive amounts of weight and your skin is rubbing or
chafing, always document it. Always tell your primary care
so that it’s all in there so you have a good case for
insurance for it to be covered. – Next question, I got a postcard saying I could get this procedure in Chelsea. Can I do all of it, tests,
surgery, counseling, in Chelsea? And is it still U of M? – Great question. So the answer to that is yes.
– I’m so jealous. – For all those components
of the question. So our program is University
of Michigan Bariatric Program. We offer our services both before surgery, the actual surgery itself,
as well as aftercare, in both locations. The way that we generally
go through the process is you can be seen for your
evaluation in either location. I will say this, not all
patients may be appropriate to have their surgery in Chelsea, so that’s a determination that we make when we see them in the office, but, yes, all the services are
available in both locations. And we’re looking forward
to taking care of patients in either location. – Absolutely, absolutely. So you guys did a fantastic job. We answered every single
question, which is wonderful. – Thanks. – And we’re going towards
the end of our chat today. So, Dr. Obeid, Alex,
Christina, thank you all for sharing your time. Thank you for sharing your perspective. That was fantastic.
– Thank you. – If any of our viewers are interested in sharing today’s recording with others, obviously you’ll find it on
our Facebook page later today and also on the Michigan
Medicine YouTube channel shortly thereafter. So, again, thank you all for joining us. Thank you to our viewers for
all these questions as well and have a wonderful afternoon.

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