June 17, 2023
Exploring Modern Bariatric Techniques and Their Benefits
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Are you curious about bariatric surgery? In this captivating episode, Dr Gavin Nimon (Orthopaedic Surgeon) interviews Dr. Ben Teague, a general surgeon and bariatric specialist, as we uncover the health risks associated with excess weight and how bariatric surgery can be a life-changing solution for many. Dr. Teague shares valuable insights about the medical conditions associated with obesity, while also discussing various surgical options and their benefits.
Bariatric surgery has come a long way from the non-adjustable gastric bands of the 1990s. Today, we outline the options of laparoscopic procedures like the sleeve gastrectomy, and their potential benefits. Dr. Teague also sheds light on the risks and side effects associated with these surgeries. Don't miss this enlightening conversation with Dr. Ben Teague as we navigate the complex world of obesity and bariatric surgery.
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While it's essential to respect and acknowledge the diversity of individual body shapes and sizes, it's equally important to understand the potential health risks that excessive weight can pose, as it may lead to chronic conditions and compromise overall well-being.
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Obesity has been associated with many medical conditions, some of which are life shortening, as well as cancers, and some can affect quality of life.
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For those individuals suffering from the effects of excessive weight who have been unable to lose weight, bariatric surgery exists.
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But what is bariatric surgery?
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What are the risks of it?
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When is it indicated?
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Well, today we learn more.
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Good day and welcome to Aussie Med Ed, the Australian Medical Education Podcast, a Program born tdborn during COVID times, to emulate that general chit, chat and banter around the hospital with the idea of educating the medical student and GP alike.
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I'm Gavin Nimon, an orthopedic surgeon based in Adelaide, and it's my pleasure to bring Aussie Med Ed to you.
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And, as new innovation for our podcast, i'd like to announce that we now have the option for the listener to leave a question so that we can answer this at another episode.
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Feel free to access our podcast website, medicalpodcasteraucom, and I'll leave an audio message via the link on the right hand side on the front page where you can type a question in via the link at the bottom of the website.
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The best question will be featured in the next episode and will be answered via re-interviewing that interviewee on that particular topic.
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And today we're joined by Dr Ben Teague.
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He's a general surgeon practicing in South Australia and he specialises in bariatric surgery.
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Having completed his training in South Australia as a general surgeon, he had to talk a fellowship at the McMaster University at Hamilton, ontario, including undertaking specialist training in bariatric surgery.
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We now work as a general surgeon in Modbury and in Ashford hospitals and his interests are laparoscopic surgery, including bariatric surgery.
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Ben's going to give us his experience of bariatric surgery and outline the indications for surgery, who particularly benefits from it and what the options of surgery are.
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I'd like to start by acknowledging the traditional owners of the land on which this podcast has been produced, the Garner people, and pay my respect to the elders, both past, present and emerging.
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Now it's my pleasure to introduce Dr Ben Teague, a general surgeon working here in Adelaide, both as a general surgeon as well as a specialist bariatric surgeon.
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Welcome, dr Ben Teague.
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Good morning Gavin.
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Yes, thanks, ben.
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Thanks for coming on Aussie MedEd.
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But whilst I understand that obesity is obviously a complex issue with many factors causing it, including genetic and environmental factors, i hope she can help our listeners understand what the implications of occurring excessive amount of weight are and also talk about what the incidence of it is in Australia.
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Yes, look, it's estimated about two thirds of our population is either overweight or obese.
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We can measure that in various ways, but generally a BMI of over 30 is considered obese, and that's where we start to have some medical concerns and start looking for medical issues.
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And what issues or medical problems can arise in this scenario once you get a BMI over 30?
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Look, lots of health issues.
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Metabolic syndrome is increasingly common.
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That's association between ischemic heart disease, central trunkal obesity, things like hypertension, diabetes, myelitis that's a big issue in our community.
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Obstructive sleep apnea is a major issue in your area, Gavin.
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Osteoarthritis, joint issues, things like hyper cholesterolemia a multitude of issues can occur with increasing weight.
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I believe some cancers also associate with it as well.
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Is that correct?
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Yeah, look, breast cancer, for example, has been associated with obesity.
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So a number of cancers and health impacts.
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If you look at people who are obese, they do have a shorter life expectancy, particularly when you're getting over a BMI 35 and when you start to diagnose other conditions.
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There is some ethnic variability, but certainly number of health impacts of weight.
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So obviously it's a very important issue.
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Now, I suspect many of the patients you see are self-referred and have already taken on board the issue and trying to address it themselves.
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But what do you do when you see a patient who is overweight and you realize that it is causing some medical issues?
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Whilst I know it's important to always respect individual circumstances and the body habitus, obviously, if the weight's causing some medical problems, it's important to address this, and I find it tricky to how to approach the scenario.
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Do you have any tips on how you go about addressing this scenario of a patient who's overweight and is causing some medical complications?
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Yes, as you said, a number of patients come to us directly because of their weight and that's usually a more straightforward issue, but I also work as a general surgeon.
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I see patients with hernias, i see patients with gallbladder problems, other issues, bowel issues, and many of them their weight is impacting on their health and I think, much the same as we would identify smoking as a risk factor and I think a lot of doctors now are happy and comfortable about talking about smoking We should also be aware of weight as an issue.
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Some of the things that I think are important are using objective measures, things like body mass index or waist circumference.
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These are objective and can be given to the patient in a non-judgmental fashion and it's also something that the patient can then use to assess and monitor their health.
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and, i think, relating the issue of weight back to the particular issue that the patient's presented with.
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So if they've come in with an umbilical hernia and they have central abdominal obesity and they do have herniation of intraabdominal fat, then I think talking about the benefits of weight loss in that patient is important for the patient.
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What are your steps for actually working up that patient?
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Are there other factors or medical issues you might want to assess to try and help reduce the weight gain?
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People always concerned about thyroid issues or other medications that might be on the course of weight.
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What's your general workup?
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Yeah, look, i think fortunately in Australia we have a very good primary health system and most people will have a GP and many people who've been looking at their weight have been dealing with this for some time.
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Before I've seen specialists, but, yeah, they would have most likely had a workup, including thyroid function tests.
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But also looking at baseline nutritional levels.
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Many patients have poor nutrition that may be calorie-rich but they poor in other areas Their nutrition.
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So looking at things like vitamin D levels l folate is important.
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I think.
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Just getting an assessment of what the patient has tried so far and what sort of interventions they're working with, what their exercise levels are, a bit of a dietary history and if they've used any medications in the past.
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These are all good things to start with a patient and then looking at their comorbidity.
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So what is their blood pressure, what is their heart, what is their blood glucose level Those sorts of things, their cholesterol level, and again, that can be helpful because they may present with one problem but they might uncover other health issues that are related.
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You've already mentioned the use of the general practitioner and the help they provide.
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Are there any other allied health professionals you might involve in actually the workup as well?
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Yeah, look, i think allied health is extremely important.
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I think, unfortunately, access to allied health can be difficult.
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Some people are concerned about costs and other people are resistant to engaging other specialists, but I think the key team is a dietitian and honestly I think dietitians probably that should be the start of the process and the exercise specialist, so exercise physiologists, physiotherapists and also often a psychologist.
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I think that's a very important area which sometimes gets overlooked.
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So, to generalise the team approach in this scenario, what about those patients who blame either a low resting heart rate or some genetic factors in the cause of their weight gain?
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The fact they've always been overweight does it change the importance of trying to lose weight and also the effectiveness of doing so?
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Look, i think it's always important to come back to what the patient's goals are, so I tend to try and identify with a patient what their goals are and what they see the issues as.
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If they're not ready to address their weight, then that can be difficult.
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I think it's something that you want to do in conjunction with a patient.
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Or if they don't see their weight as important, again, it's more about giving them information at that level.
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But, look, i think, fortunately, most patients that come to doctors to look for help with their weight are looking for solutions and they are open to advice and to approaches, including multidisciplinary approaches, medical approaches and surgical approaches.
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Whilst patients often hope that there is a cause for their weight gain, such as hyperthyroidism or some other endocrine problem.
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Is that common or is it pretty rare scenario for that to develop?
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and it's often other factors, including dietary intake etc.
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Look, it's rare for me to see patients with other issues because I think, again, the GPs identify those issues early and referring those patients onto endocrinologists.
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Look, i think a large number of our patients are on thyroid medication and are controlled with their thyroid medication, so there's no simple answer to their weight.
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From that point of view, i think metabolism is a very interesting area.
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As we aid, our metabolism slows.
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I think many of us, myself included, are familiar with the fact that I can't eat the same amount of food that I did when I was younger.
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I don't exercise as much and my metabolism is slower.
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So I think metabolism is an area which is interesting, but I think we have to work with the metabolism that we have.
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We don't have any good medications at the moment, other than if we're thyroid depleted or hyperthyroid.
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We don't have a simple answer to low metabolism levels, so we have to work with the metabolism that we have.
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I think exercises are really important way of stimulating metabolic levels.
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So I try to encourage people to exercise if they've got low metabolism levels and work with an exercise physiologist if necessary.
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That's really an interesting point, because people can have the same fitness training at the same level but finding some are burning calories quicker than others.
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And you don't have to be the same as everyone around you.
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You just have to be at a weight that's healthy for you and you need to work with the genetic predisposition that you've been served up.
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Excellent.
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We've talked about the health benefits of weight loss, but what about the psychological benefits of weight loss as well?
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Certainly there are people.
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When they lose weight, they feel better for themselves and feel more confident.
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Is that a common scenario?
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Yes, i think that many of us will have experienced that if we've lost weight, we've got some compliments from others and we've got a bit more confidence.
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Sometimes we feel bad about our weight and that stops us from doing things or going places.
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I think it's important also to recognize that your weight is not the determinant of your psychological well-being.
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Sometimes we feel that if we lost weight our lives would be better, and then we address our weight and we lose weight and we still have many of the same stresses and concerns we had before because they're not related to our weight.
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So I think it's important to be realistic about some of the psychological benefits, but I think certainly there is.
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anecdotally, I notice improvement in people's well-being and confidence if they've been successful in addressing weight concerns.
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Yeah, that's a brilliant point.
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Moving on to the treatment of weight loss, i know obviously we've talked about the importance of reducing dietary intake and involving a dietitian and psychologist in the management.
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We've also talked about the importance of exercise, but we might move on to something like medications.
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I know in the past, emily Myers, on our Diabetic Talk, talked about the use of a Zempik or GLP1 agonist.
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I believe this has a side effect of making people less hungry.
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Do you use these medications in your management as well?
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What other medications do you incorporate as part of your practice?
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Yeah, look, i work with GPs that prescribe those medications.
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Some of those medications like Ozempic for example is not currently approved for weight loss in Australia, although it is in other countries.
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I think this is a really interesting area and I think it's an area which is going to evolve rapidly over the coming years.
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I think prior to the advent of some of these new agents, we had older medical agents, things that people might be familiar with.
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Medications such as Duromine, which has been around for a long time, had a lot of side effects and wasn't suitable for long-term use.
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I think certainly even five, ten years ago I had a rather cynical approach to some of the medications that are out there for weight loss.
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Now I think the new medications are much more exciting, things like Saxenda or Ozempik.
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Those agents or similar agents will play part of the future.
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They can be useful in patients who have moderate levels of obesity, who are trying to lose moderate amount of weight, and that weight loss can show patients the health improvement with that and that's maybe something that they can then continue to work on, with or without medication.
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There will be other patients that have a specific weight loss goal for a specific reason, such as preoperative weight loss and medication may be useful for that.
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And again, some people might be looking at long-term use for management of obesity.
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I think it's an area that's evolving.
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These are new agents.
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We don't entirely know what the long-term effects are going to be, but I think it's an exciting area.
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Brilliant.
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Do you think these medications are such that one day we won't require bariatric surgery and that these medications will do the job for you?
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Look, i think we're always looking for that golden bullet, and one day I would hope that we're not doing bariatric surgery anymore.
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I think realistically, though, what we're seeing now is an increased awareness in the population.
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We operate on probably about 1% of the population that are obese or less, and so there's a lot of obese patients out there who would benefit from medication.
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So I think, more realistically, it's going to enable us to treat a larger number of patients, and there will still be a role for bariatric surgery in some patients.
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I've also had the anecdotal experience of people enjoying the benefit of medical weight loss and then choosing to go on and have surgical procedures to replicate that weight loss long-term.
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Brilliant Look.
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assuming people are motivated to try and lose weight, improve their general health and have tried these other measures, they then move on to come and see someone like yourself for bariatric surgery.
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What are the inclusion criteria for doing it?
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What sort of patient would you choose and what do they need to consider when they're going down this pathway?
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Generally we're looking at patients with, certainly, bmi over 30, but generally over 35.
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We're looking at their comorbidities.
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So generally, patient with a BMI over 40, which we call class 3 obesity, with or without comorbidity, we consider surgical management.
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Patients with BMI over 35 or class 2 obesity who have weight-related comorbidity, that's another group of patients.
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There are some patients with BMI 30 to 35, particularly patients with diabetes and other conditions where we might consider weight loss surgery, and there are some ethnic groups in which BMI 30 to 35 might be considered an indication for surgery.
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So those would be the sort of medical indications.
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Other indications for patients, as you say, need to have engaged in other weight loss measures, they need to be stable from a psychological point of view and they shouldn't be abusing drugs, including alcohol.
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So those are the criteria that we'd be looking at.
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Are there any medical contraindications for considering surgery?
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Look, i think advanced age, So people over the age of 65 you want to be careful with.
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It's difficult.
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Sometimes the sicker patients are the ones that need surgery more So in a young patient who's got, for example, cardiovascular morbidity or other significant comorbidity, their risk factors may actually be the reason for their surgery rather than a contraindication to their surgery.
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But it's very important to be mindful of the risk of surgery as well.
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Patients may need medical workup preoperatively to make sure that they're optimized for surgery.
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What sort of surgical procedures are undertaken?
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When I was going through medical school, we understood the partial gastrectomy, But a lot of these procedures in fact most of them are done laparoscopically.
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Now, What are the options of treatment?
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Yes, in barrage, etc.
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There's a long history of different procedures that are, some of which have come and gone, and there's been changes and advances over the years.
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Initially, around the 1960s, a US surgeon, Dr Mason, proposed the idea of the Roux -en-Y gastric bypass, which some of our colleagues will be familiar with.
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That's an operation where the stomach is stapled and divided and a small gastric pouch is created separating the upper stomach from the lower stomach.
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A loop of jejunum small bowel is then brought up to the stomach and anastomose to the small gastric pouch And then lower down a second anastomosis is made in a Y-fashion which then joins the billary drainage from the jewerdenum and the liver to the alimentary limb which comes from the stomach down towards the common channel which then travels down to the isleosychromium.
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So that's a bit of a complicated procedure.
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When it was first proposed it was open surgery and was a very big undertaking.
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And over the years surgeons have tried to improve on that procedure, either with less invasive approaches, such as laparoscopic surgery, or with modifications of the surgery.
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So we went through the era of the gastric band, the adjustable gastric band, but prior to that non-injustable gastric band.
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So that was an era from about the 1990s onwards, where a piece of silastic rubber was placed around the top of the stomach and that could be inflated or deflated with a balloon via a port under the skin, and that was a very straightforward operation compared to the gastric bypass.
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It was quite simple and could be done laparoscopically, which at the time was not possible for the gastric bypass, and that really revolutionized barrage surgery for some patients and led to certainly in Australia an increase in the number of procedures performed.
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That operation has actually gone a little bit out of fashion recently.
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It did have long term.
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It had some issues related to it which meant there wasn't as effective or safe as we thought it might have been, and there's been now a turn towards operations such as the sleeve gastrectomy and modifications of the gastric bypass, all performed laparoscopically.
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That's truly amazing.
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You can perform such a procedure through a telescope.
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What's the most common procedure you perform?
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Is it the sleeve gastrectomy?
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Yeah, so across Australia now about 80% of bariatric procedures are sleeve gastrectomies.
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The sleeve gastrectomy is taking the stomach and removing the majority of the stomach to create a small tubular stomach which really acts as a conduit, rather than the traditional idea we have of the stomach as the initial place for mechanical and acid digestion.
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We all have stomachs.
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We've evolved that because it enables us to process a relatively large meal and that food, since the stomach, can get processed and then delivered to the small bowel over a longer period And that's helpful when you don't have access to food all the time.
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The sleeve gastrectomy changes that stomach from that initial processing organ into really a small tube which really just transmits the food more rapidly through to the small bowel And that enables patients to eat a smaller meal, to feel more comfortable with that small meal, that small portion, and to be less hungry and to eat less calories.
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So that's the most common procedure.
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About 80 percent of patients across Australia are currently having that operation.
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The other 20 percent are primarily the good old fashioned Roux-en-Y Gastric Bypass and a newer version of that called the one in astimosis gastric bypass or loop gastric bypass, which is an adaptation where instead of a Y construction we're simply looping a small bowel loop onto the stomach with one join rather than the two joins of the traditional Rewire Gastric Bypass.
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So about 10 percent each of the Rewire Gastric Bypass and the one in astimosis gastric bypass are performed currently as primary procedures.
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How would you decide which patient would have which procedure?
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There are particular indications for one over the other.
00:19:54.266 --> 00:20:00.013
Generally, patients do have a fair amount of choice and election in which operation that they might pursue.
00:20:00.013 --> 00:20:04.195
Some operations have an advantage in particular patients.
00:20:04.195 --> 00:20:10.375
There is a suggestion sometimes that patients with more advanced diabetes might benefit more from a bypass than from a sleeve.
00:20:10.375 --> 00:20:15.673
Patients who have significant reflux issues may benefit more from a bypass than a sleeve.
00:20:15.673 --> 00:20:18.313
But generally patients have some degree of election.
00:20:18.313 --> 00:20:20.432
None of these operations are perfect.
00:20:20.432 --> 00:20:37.153
They all have their pluses and minuses, risks and benefits, And I think it's important that patients have a good understanding of all the options that are available to them and that helped to make their own choices in that process And then proceed to surgery with a fully informed decision.
00:20:37.545 --> 00:20:38.348
It's truly amazing.
00:20:38.348 --> 00:20:40.772
Are there any procedures now where you actually put implants in?
00:20:40.772 --> 00:20:41.969
There used to be balloons
00:20:46.845 --> 00:20:48.632
here is a version that's around currently.
00:20:48.632 --> 00:20:52.796
The latest advance in balloons is these are intragastric balloons.
00:20:52.796 --> 00:20:55.974
We used to place them endoscopically into the stomach.
00:20:55.974 --> 00:20:59.791
They would take up a fair amount of room in the stomach and then give patients satiety.
00:20:59.791 --> 00:21:08.233
The latest example of the balloon is one that the patients follow themselves does not require an endoscopy to place the balloon.
00:21:08.233 --> 00:21:16.672
The balloons have always been limited by questions about how long they will last for and the long-term benefits of the balloon.
00:21:16.672 --> 00:21:20.568
They also have some short-term side effects and they're quite costly.
00:21:20.568 --> 00:21:28.453
At the moment They're not covered at all by your private insurer or by Medicare And I think that's limiting access to the balloon at this point.
00:21:29.204 --> 00:21:32.750
With the surgical procedures, the Roux-en-Y or the sleeve gastrectomy.
00:21:32.750 --> 00:21:35.851
How many portals does that involve and how long is a patient in hospital?
00:21:35.851 --> 00:21:37.450
four, and how long does a procedure take?
00:21:38.125 --> 00:21:41.915
So the laparoscopic procedures take about 60 to 90 minutes.
00:21:41.915 --> 00:21:56.835
They are five laparoscopic incisions generally And patients in hospital for as little as one day but median length of stay is probably around two to three days two days for a sleeve and three for gastric bypass.
00:21:56.835 --> 00:22:02.317
Length of stay can vary depending on the hospital setup that you have.
00:22:02.317 --> 00:22:14.951
In the US there is a move towards same day or overnight stay, whereas in Australia, i think lengths of stay probably another 24 to 48 hours longer in general, given a hospital system.
00:22:14.951 --> 00:22:16.013
Wow.
00:22:16.705 --> 00:22:25.135
These minimally invasive surgical procedures come about because of the advance in both the telescopes and the cameras, as well as the stapling guns that help you do it.
00:22:25.135 --> 00:22:27.554
Or is that the main limiting factor in the past?
00:22:27.554 --> 00:22:29.813
or is it just the skills of just evolve with time?
00:22:30.525 --> 00:22:47.373
I think the major advance has been in the devices that we have access to, particularly hemostatic devices, things like the ultrasonic detectors and bipolar detectors, which enable us to divide tissues and control bleeding, which is very important in laparoscopic surgery.
00:22:47.373 --> 00:22:48.469
Is it any significant?
00:22:48.469 --> 00:22:51.611
bleeding can make your surgery quite difficult and obscure your vision.
00:22:51.611 --> 00:23:00.333
And, of course, the various stapling devices enable us to safely join the bowel or to divide the stomach safely.
00:23:00.333 --> 00:23:04.971
Those have been the major advances, So we're very reliant on that technology.
00:23:04.971 --> 00:23:23.676
The anastomosis of bowel and the division of the stomach are critical And if there are leaks or anastomotic failures then that's a major complication which can turn a good operation with a one to two day stay into a very dramatic long stay with multiple surgeries.
00:23:23.676 --> 00:23:28.913
So that's been a very important part of introducing safe laparoscopic surgery.
00:23:29.704 --> 00:23:35.491
Are there any other risks for the surgery, such as infections or deep vein thrombosis or cardiovascular complications?
00:23:36.184 --> 00:23:39.675
Yeah, look, laparoscopic surgery is fantastic.
00:23:39.675 --> 00:23:43.673
It enables us to perform surgery safely, but there's always a level of risk.
00:23:43.673 --> 00:23:52.034
So the risk of surgery, of major complications within 90 days of surgery probably range from about one to 5%, depending on the procedure.
00:23:52.034 --> 00:24:03.272
From a patient perspective, that means that 95 to 99% of patients will come through without a complication, but there'll be those one to 5% who do have significant complications.
00:24:03.272 --> 00:24:12.432
So they can include, as you say, cardiovascular issues such as deep vein thrombosis and pulmonary embolism, which is rare, less than 1%.
00:24:12.432 --> 00:24:24.470
Then you have issues with healing, either leakage from anastomosis or stable lung breakdown, and then also issues such as bleeding, damage to other organs.
00:24:24.470 --> 00:24:34.311
So there are risks with surgery and that's very important to convey those risks to the patients before surgery and, if they develop complications, post-surgery, to manage those complications.
00:24:34.945 --> 00:24:40.490
I read also that there's possibly other side effects of surgery, such as dumping syndrome or development of gallstones.
00:24:40.490 --> 00:24:41.929
Do these things still occur?
00:24:42.746 --> 00:24:56.193
No, i think one of the important things about weight loss surgery and we're also seeing this with medical weight loss is that the surgery is simply the beginning of a long-term process of managing that patient and there will be issues that arise down the track.
00:24:56.193 --> 00:25:05.852
These can be issues such as nutritional impact with nutritional deficiencies, gallstones, hernias other issues that we create because of the surgery.
00:25:05.852 --> 00:25:08.413
Also reflux and esophagitis.
00:25:08.413 --> 00:25:15.034
It's very important that patients have long-term follow-up and long-term management and are committed to that.
00:25:15.034 --> 00:25:21.690
Gallstones probably occur in about one to 10% of patients after surgery.
00:25:21.690 --> 00:25:28.470
Many of our patients will have actually already had their gallbladder taken out at some point because obesity is also a risk factor for gallstones.
00:25:28.470 --> 00:25:37.888
But sudden and dramatic weight loss can lead to gallstones or increased symptoms with gallstones, and we certainly see patients that require cholesterol to stick to me.
00:25:37.888 --> 00:25:47.744
Reflux related to some of the surgeries, particularly sleeve gastrectomy, but also gastric band, can lead to esophagitis and esophageal problems.
00:25:47.744 --> 00:25:50.578
It's important to monitor those patients as well.
00:25:51.250 --> 00:25:58.523
Is there a requirement for, after the surgery, for a regular follow-up with endoscopies to monitor for the development of esophagitis or development of barit's esophagus?
00:26:00.132 --> 00:26:01.053
Increasingly.
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