Exploring Modern Bariatric Techniques and Their Benefits

Gavin Nimon: 0:28

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. 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. For those individuals suffering from the effects of excessive weight who have been unable to lose weight, bariatric surgery exists. But what is bariatric surgery? What are the risks of it? When is it indicated? Well, today we learn more. 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. I'm Gavin Nimon, an orthopedic surgeon based in Adelaide, and it's my pleasure to bring Aussie Med Ed to you. 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. 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. The best question will be featured in the next episode and will be answered via re-interviewing that interviewee on that particular topic. And today we're joined by Dr Ben Teague. He's a general surgeon practicing in South Australia and he specialises in bariatric surgery. 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. We now work as a general surgeon in Modbury and in Ashford hospitals and his interests are laparoscopic surgery, including bariatric surgery. 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. 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. 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. Welcome, dr Ben Teague.

Ben Teague: 2:35

Good morning Gavin.

Gavin Nimon: 2:36

Yes, thanks, ben. Thanks for coming on Aussie MedEd. 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.

Ben Teague: 2:54

Yes, look, it's estimated about two thirds of our population is either overweight or obese. 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.

Gavin Nimon: 3:09

And what issues or medical problems can arise in this scenario once you get a BMI over 30?

Ben Teague: 3:15

Look, lots of health issues. Metabolic syndrome is increasingly common. That's association between ischemic heart disease, central trunkal obesity, things like hypertension, diabetes, myelitis that's a big issue in our community. Obstructive sleep apnea is a major issue in your area, Gavin. Osteoarthritis, joint issues, things like hyper cholesterolemia a multitude of issues can occur with increasing weight.

Gavin Nimon: 3:40

I believe some cancers also associate with it as well. Is that correct?

Ben Teague: 3:43

Yeah, look, breast cancer, for example, has been associated with obesity. So a number of cancers and health impacts. 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. There is some ethnic variability, but certainly number of health impacts of weight.

Gavin Nimon: 4:06

So obviously it's a very important issue. 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. But what do you do when you see a patient who is overweight and you realize that it is causing some medical issues? 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. 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?

Ben Teague: 4:36

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. 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. Some of the things that I think are important are using objective measures, things like body mass index or waist circumference. 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. and, i think, relating the issue of weight back to the particular issue that the patient's presented with. 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.

Gavin Nimon: 5:42

What are your steps for actually working up that patient? Are there other factors or medical issues you might want to assess to try and help reduce the weight gain? People always concerned about thyroid issues or other medications that might be on the course of weight. What's your general workup?

Ben Teague: 5:56

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. Before I've seen specialists, but, yeah, they would have most likely had a workup, including thyroid function tests. But also looking at baseline nutritional levels. Many patients have poor nutrition that may be calorie-rich but they poor in other areas Their nutrition. So looking at things like vitamin D levels l folate is important. I think. 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. These are all good things to start with a patient and then looking at their comorbidity. 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.

Gavin Nimon: 6:58

You've already mentioned the use of the general practitioner and the help they provide. Are there any other allied health professionals you might involve in actually the workup as well?

Ben Teague: 7:06

Yeah, look, i think allied health is extremely important. I think, unfortunately, access to allied health can be difficult. 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. I think that's a very important area which sometimes gets overlooked.

Gavin Nimon: 7:36

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? The fact they've always been overweight does it change the importance of trying to lose weight and also the effectiveness of doing so?

Ben Teague: 7:52

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. If they're not ready to address their weight, then that can be difficult. I think it's something that you want to do in conjunction with a patient. Or if they don't see their weight as important, again, it's more about giving them information at that level. 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.

Gavin Nimon: 8:29

Whilst patients often hope that there is a cause for their weight gain, such as hyperthyroidism or some other endocrine problem. Is that common or is it pretty rare scenario for that to develop? and it's often other factors, including dietary intake etc.

Ben Teague: 8:42

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. 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. From that point of view, i think metabolism is a very interesting area. As we aid, our metabolism slows. 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. I don't exercise as much and my metabolism is slower. So I think metabolism is an area which is interesting, but I think we have to work with the metabolism that we have. We don't have any good medications at the moment, other than if we're thyroid depleted or hyperthyroid. We don't have a simple answer to low metabolism levels, so we have to work with the metabolism that we have. I think exercises are really important way of stimulating metabolic levels. So I try to encourage people to exercise if they've got low metabolism levels and work with an exercise physiologist if necessary.

Gavin Nimon: 9:45

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.

Ben Teague: 9:51

And you don't have to be the same as everyone around you. 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.

Gavin Nimon: 10:03

Excellent. We've talked about the health benefits of weight loss, but what about the psychological benefits of weight loss as well? Certainly there are people. When they lose weight, they feel better for themselves and feel more confident. Is that a common scenario?

Ben Teague: 10:15

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. Sometimes we feel bad about our weight and that stops us from doing things or going places. I think it's important also to recognize that your weight is not the determinant of your psychological well-being. 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. So I think it's important to be realistic about some of the psychological benefits, but I think certainly there is. anecdotally, I notice improvement in people's well-being and confidence if they've been successful in addressing weight concerns.

Gavin Nimon: 11:00

Yeah, that's a brilliant point. 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. We've also talked about the importance of exercise, but we might move on to something like medications. I know in the past, emily Myers, on our Diabetic Talk, talked about the use of a Zempik or GLP1 agonist. I believe this has a side effect of making people less hungry. Do you use these medications in your management as well? What other medications do you incorporate as part of your practice?

Ben Teague: 11:30

Yeah, look, i work with GPs that prescribe those medications. Some of those medications like Ozempic for example is not currently approved for weight loss in Australia, although it is in other countries. 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. I think prior to the advent of some of these new agents, we had older medical agents, things that people might be familiar with. 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. 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. Now I think the new medications are much more exciting, things like Saxenda or Ozempik. Those agents or similar agents will play part of the future. 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. 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. And again, some people might be looking at long-term use for management of obesity. I think it's an area that's evolving. These are new agents. We don't entirely know what the long-term effects are going to be, but I think it's an exciting area.

Gavin Nimon: 13:04

Brilliant. 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?

Ben Teague: 13:12

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. I think realistically, though, what we're seeing now is an increased awareness in the population. 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. 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. 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.

Gavin Nimon: 13:56

Brilliant Look. 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. What are the inclusion criteria for doing it? What sort of patient would you choose and what do they need to consider when they're going down this pathway?

Ben Teague: 14:15

Generally we're looking at patients with, certainly, bmi over 30, but generally over 35. We're looking at their comorbidities. So generally, patient with a BMI over 40, which we call class 3 obesity, with or without comorbidity, we consider surgical management. Patients with BMI over 35 or class 2 obesity who have weight-related comorbidity, that's another group of patients. 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. So those would be the sort of medical indications. 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. So those are the criteria that we'd be looking at.

Gavin Nimon: 15:17

Are there any medical contraindications for considering surgery?

Ben Teague: 15:21

Look, i think advanced age, So people over the age of 65 you want to be careful with. It's difficult. 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. But it's very important to be mindful of the risk of surgery as well. Patients may need medical workup preoperatively to make sure that they're optimized for surgery.

Gavin Nimon: 15:53

What sort of surgical procedures are undertaken? 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. Now, What are the options of treatment?

Ben Teague: 16:03

Yes, in barrage, etc. 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. 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. 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. 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. So that's a bit of a complicated procedure. When it was first proposed it was open surgery and was a very big undertaking. 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. So we went through the era of the gastric band, the adjustable gastric band, but prior to that non-injustable gastric band. 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. 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. That operation has actually gone a little bit out of fashion recently. It did have long term. 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.

Gavin Nimon: 18:25

That's truly amazing. You can perform such a procedure through a telescope. What's the most common procedure you perform? Is it the sleeve gastrectomy?

Ben Teague: 18:33

Yeah, so across Australia now about 80% of bariatric procedures are sleeve gastrectomies. 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. We all have stomachs. 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. 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. So that's the most common procedure. About 80 percent of patients across Australia are currently having that operation. 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. So about 10 percent each of the Rewire Gastric Bypass and the one in astimosis gastric bypass are performed currently as primary procedures.

Gavin Nimon: 20:17

How would you decide which patient would have which procedure? There are particular indications for one over the other.

Ben Teague: 20:22

Generally, patients do have a fair amount of choice and election in which operation that they might pursue. Some operations have an advantage in particular patients. There is a suggestion sometimes that patients with more advanced diabetes might benefit more from a bypass than from a sleeve. Patients who have significant reflux issues may benefit more from a bypass than a sleeve. But generally patients have some degree of election. None of these operations are perfect. 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.

Gavin Nimon: 21:06

It's truly amazing. Are there any procedures now where you actually put implants in? There used to be balloons

Ben Teague: 21:15

here is a version that's around currently. The latest advance in balloons is these are intragastric balloons. We used to place them endoscopically into the stomach. They would take up a fair amount of room in the stomach and then give patients satiety. The latest example of the balloon is one that the patients follow themselves does not require an endoscopy to place the balloon. The balloons have always been limited by questions about how long they will last for and the long-term benefits of the balloon. They also have some short-term side effects and they're quite costly. 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.

Gavin Nimon: 21:57

With the surgical procedures, the Roux-en-Y or the sleeve gastrectomy. How many portals does that involve and how long is a patient in hospital? four, and how long does a procedure take?

Ben Teague: 22:06

So the laparoscopic procedures take about 60 to 90 minutes. 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. Length of stay can vary depending on the hospital setup that you have. 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. Wow.

Gavin Nimon: 22:45

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. Or is that the main limiting factor in the past? or is it just the skills of just evolve with time?

Ben Teague: 22:59

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. Is it any significant? bleeding can make your surgery quite difficult and obscure your vision. And, of course, the various stapling devices enable us to safely join the bowel or to divide the stomach safely. Those have been the major advances, So we're very reliant on that technology. 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. So that's been a very important part of introducing safe laparoscopic surgery.

Gavin Nimon: 23:58

Are there any other risks for the surgery, such as infections or deep vein thrombosis or cardiovascular complications?

Ben Teague: 24:04

Yeah, look, laparoscopic surgery is fantastic. It enables us to perform surgery safely, but there's always a level of risk. So the risk of surgery, of major complications within 90 days of surgery probably range from about one to 5%, depending on the procedure. 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. So they can include, as you say, cardiovascular issues such as deep vein thrombosis and pulmonary embolism, which is rare, less than 1%. 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. 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.

Gavin Nimon: 25:03

I read also that there's possibly other side effects of surgery, such as dumping syndrome or development of gallstones. Do these things still occur?

Ben Teague: 25:11

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. These can be issues such as nutritional impact with nutritional deficiencies, gallstones, hernias other issues that we create because of the surgery. Also reflux and esophagitis. It's very important that patients have long-term follow-up and long-term management and are committed to that. Gallstones probably occur in about one to 10% of patients after surgery. 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. 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. Reflux related to some of the surgeries, particularly sleeve gastrectomy, but also gastric band, can lead to esophagitis and esophageal problems. It's important to monitor those patients as well.

Gavin Nimon: 26:19

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?

Ben Teague: 26:28

Increasingly. Some of the surgical obesity groups are recommending routine endoscopy post-surgery. But at the moment that's a recommendation rather than a strict guideline. But I think increasingly that's an area that we will be looking at more closely. Is endoscopic monitoring post-surgery.

Gavin Nimon: 26:44

Now, how successful are these procedures overall? There must be some sort of review of them down the track, some sort of audit. What sort of figures are we expecting to get?

Ben Teague: 26:53

Some of the best data we're getting in Australia at the moment is coming out at the Australian bariatric surgery registry, which is a nationwide registry which is encapsulating a large number of surgical centres which are performing obesity surgery. That is registry data which is being collected and monitored long term. We're not looking at a great detail, but we are looking at things like complications, weight loss and diabetes. In particular, The registry data shows us that with sleeves and gastric bypass we're looking at around a third of total body weight loss between one and three years post-surgery And we're looking at about 70% resolution of insulin requirements for diabetes and we're looking at significant improvements in diabetes in patients who are not requiring insulin-approved surgery.

Gavin Nimon: 27:46

They're pretty impressive figures. How long has the registry been going for?

Ben Teague: 27:49

The registry has been running since 2012, but really in large numbers. We've been collecting numbers from about 2018. So we will be getting more data as the registry proceeds.

Gavin Nimon: 28:00

That's pretty impressive, though It's amazing. Are there other general surgical procedures that are involved in the registry as well? We've obviously had one for orthopedics for some time now, but I wasn't aware of these other registries.

Ben Teague: 28:11

I think increasingly we're looking at registry data in various areas. I'm aware that there are registries, for example, in cancer surgery, in breast and colon, in vascular surgery. I think registry data gives you a good idea of real-world data because it's people having surgery outside of a trial, where sometimes in trials we see very selected patients having selected outcomes. So it's really giving us a good idea of what the real-world data is.

Gavin Nimon: 28:39

Now I know in the past laparoscopic bandings have failed because people haven't tolerated the sensation of the fullness or the laparoscopic band. Is there a failure rate of the surgeries? What sort of figures are we looking at for failure rates in these particular procedures?

Ben Teague: 28:51

Yes. So if you look at all the operations over time, there is a failure rate either weight regain or development of complications which requires surgical intervention. I think there's good data from Sweden where they've followed people up for about 20 years now. That shows that after about three to five years there can be weight regain. In the Swedish experience the operated groups still maintained their weight loss, even up to 20 years greater than patients that hadn't had surgery. But I think between about three and five years there's a time that we can have weight gain and that's really important to manage with patients to prevent patients trending back to their preoperative weight. We've seen with gastric bands about 50% to two-thirds of patients having revision surgery. So that's quite a high level and I think that's what led to a reduced number of gastric bands being performed. So I think it's important to support patients long term. The operations tend to reset your weight to a lower level but, as we've all experienced over time, so weight regain is possible and needs to be managed.

Gavin Nimon: 30:03

What surgical procedure would you undertake then if you wanted to reverse it, to say someone wasn't already actual side effects of the procedure and would actually have it reversed? What can you do in that scenario?

Ben Teague: 30:13

Yeah, so revision surgery is a major area of our practice and will become important long term. About 30% of the operations that I do are revisions of people who've had previous surgery, particularly the gastric band. The gastric band removal is possible and that can be a difficult procedure, but also it's less difficult than revising some of the more complicated surgeries. Sleave gastrectomy cannot be reversed but can be converted to a Rewy gastric bypass. It's possible to reverse a Roux-en-Y gastric bypass but it's difficult and that's not an operation that's commonly performed.

Gavin Nimon: 30:53

When you do the partial gastrectomy laparoscopically, you actually divide the stomach. What happens to the other half of the stomach? Does that remain in situ or is that excised through the portal?

Ben Teague: 31:01

With the sleeve gastrectomy the stomach is excised and removed, so the majority of the stomach is removed With the gastric bypass. the stomach is left in the patient and is defunctioned. This has potential issues because down the track it's quite difficult to get into that area of the stomach endoscopically and there is a potential for issues to rise in the defunctioned stomach and that's one of the issues that we have to monitor long term.

Gavin Nimon: 31:27

A question that has come to mind is the fact that the vagal nerve encircles the stomach but also supplies the heart. Is there a risk of arrhythmia after these procedures, or is that a complication that can occur in this scenario?

Ben Teague: 31:39

Generally the vagal stimulation is not related to the vagal stimulation of the heart, so those two are separated. There are actually some procedures to stimulate the vagal nerve with a pacemaker type device placed around the top of the stomach which has been used and shown to help with weight loss. That's a procedure which hasn't become a mainstream procedure but certainly there have been experimental data showing that stimulation of the vagal nerve can be important. There was a feeling that the gastric band possibly placed pressure onto the vagal nerve and that may be part of how the gastric band worked. But generally we don't see vagal issues in our patients after bariatric surgery.

Gavin Nimon: 32:18

Excellent In the post-operative period and once someone is recovering from the surgery. The role of exercise and going back to the psychologist and the exercise physiologist to help them also support the surgery Is that important as well?

Ben Teague: 32:31

I think it's important that patients are encouraged to rehabilitate post-surgery and return to normal levels of exercise, healthy eating and good psychological well-being. I think this is an area where we could do more for our patients, but often patients are feeling very good after surgery anyway because they're losing weight, and I think that can lead in some ways to some complacency as well. This period has been termed the honeymoon period. Weight loss occurs almost without the patient's effort And I think that's important at this time to reinforce those underlying dietary and exercise and psychological habits that will maintain weight loss long-term. And I think in some degree, some of the weight regain that we're seeing is perhaps because of the loss of ongoing modulation of diet and exercise, because we've helped people to lose weight with surgery rather than reinforcing the underlying dietary and exercise habits.

Gavin Nimon: 33:39

Do you think there would be a role for a fitness type app to be used in that scenario as a way of help reinforcing that?

Ben Teague: 33:44

Look, our post-surgery patients are perhaps no different to patients that haven't had surgery. We could all benefit from fitness apps. We could all benefit from diet and exercise interventions. I think what many patients, with or without surgery, struggle with is the long-term maintenance of any of these interventions. All of these interventions can be shown to work well in the short term. Unfortunately, sometimes life gets in the way and our best intentions over time are eroded. So I think long-term maintenance, with or without surgery, is one of the challenges of life.

Gavin Nimon: 34:17

Final question Future advancements. Where do you think we're heading in this area? What do you think the future will hold for bariatric surgery? What do you see on horizon?

Ben Teague: 34:26

I think the big change in the future will be the increasing use of medication, which we discussed at the beginning of the podcast. I think bariatric surgery will need to find a place alongside medication and how it works with medication. I think in future there will be a need for ongoing surgical management of patients who have had surgeries already. They may need revisions. I think long-term we will still be performing primary surgery, but we're hopefully performing that in a safer manner, as with technological advances, we get better devices to help us with our surgery.

Gavin Nimon: 35:04

That's fantastic, dr Ben Teague. It's been fantastic having you on Ozymed Ed. I've learnt so much today as well and I really appreciate your time. Thank you very much for coming on Aussie Med Ed. Thank you, gavin, it's been a pleasure. Thanks very much. I'd like to thank you very much for listening to our podcast. I'd like to remind you that the information provided today is just for general medical advice and does not pertain to one particular medical condition or one way of treating a particular condition. If you have any concerns about information raised today, please do not hesitate to contact your general practitioner for further information. We hope you've enjoyed the podcast and please don't hesitate to give us a like or tell your friends about it or give us a positive review. We look forward to presenting another podcast to you in the near future on a different topic. Until then, stay safe. Thank you very much.