What Even is a Laparoscopic Sleeve Gastrectomy?

Episode2: Transcript

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Kerri: Hey guys, this is a great episode today that you won’t want to miss. I’m Kerri, the host of the HealthTalksNOW podcast brought to you by Baptist Health. A new way of life is possible. In Baptist Health, bariatric surgery and weight loss can help you make the lifestyle changes needed to reclaim your freedom. Imagine freedom from weight restrictions, from feeling out of control and freedom to be the best version of you. I sat down with Dr. John Oldham, an expert surgeon, to learn more about one popular option, the gastric sleeve surgery. We’ll discuss the ins and outs of getting the laparoscopic sleeve gastrectomy procedure along with the qualifications and risk factors. I hope you enjoy.

Kerri: Today, I have the pleasure of sitting down with Owensboro native, Dr. John Oldham, a board-certified general surgeon to learn about the gastric sleeve surgery at Baptist Health. It’s one of the most common bariatric procedures in the US but I’d love our listeners to understand the ins and outs of getting a laparoscopic sleeve procedure. And before you start, can you tell us what led you to become a bariatric surgeon?

Dr. John Oldham: Well, actually I did a lot of bariatric procedures in residency in the late 1990s and back then it was all done open procedures, big midline incision. And I saw that patients will lose weight with that and resolve a lot of their comorbidities like diabetes, hypertension, sleep apnea, but also saw all the complications that went along with those open procedures. So it wasn’t until, got out of residency around 2002 started, see that we can do these things laparoscopically and take all those bad risks of the majority of those out of the procedure and then that’s when I got involved.

Kerri: Sure. Well, it must be rewarding to see a transformative effect and life-altering effect that you have on patients with this procedure.

Dr. John Oldham: Yeah, it really is. I mean, I truly come to work every day. It’s awesome to see patients, improving their life. They’re off medications or preventing diseases in the future. It’s the small things, like patients saying that now they can go to an amusement park, fit into a roller coaster, they go to a restaurant — they don’t have to worry about the host is going to sit them at a booth that they can’t fit in. So a lot of daily issues that they have to deal with.

Kerri: Sure, I haven’t considered that before.

Dr. John Oldham: And taking the stairs, come up to the office now where they used to do that before.

Kerri: Yeah and not be out of breath. It would be life-changing with the changes. I’d love to hear about the patient journey and the personalized approach that’s taken when considering patient’s health. Specifically, what makes a good candidate for this procedure? And what are some considerations?

Dr. John Oldham: We actually operate on about 1 to 2% of the patients that actually qualify for the surgery. So we go by a term called body mass index, which is a height and weight calculation. So somebody with a body mass index of 40 or above as a candidate, they don’t have to have any comorbidities like diabetes or hypertension for insurance to cover that procedure. But for somebody with a body mass index of 35 to 39.9, most insurances require some type of comorbid… like diabetes, hypertension, sleep apnea, liver disease, something like that. So it actually goes by their body mass index, which again, height, weight, and calculation.

Kerri: Okay. What are some of the advantages of this procedure?

Dr. John Oldam: So the gastric sleeve is the most common bariatric procedure in the world today. Most common, as you said here in the United States. The reason why it’s becoming or is the most popular is because it’s getting similar results to the Roux-En-Y gastric bypass, but doesn’t have a lot of the possible complications that go along with the bypass. So with the gastric bypass, we have to worry about ulcers, we have to worry about bowel obstructions, vitamin deficiencies. With the gastric sleeve, since we’re not rerouting the intestines, all we’re doing is making the stomach much smaller. We don’t have to worry about those types of issues.

Kerri: And as you mentioned, one of the advantages is certainly obtaining the surgery in this procedure is the joint pain relief along with relief from other medical conditions and improving fertility.

Dr. John Oldham: Exactly, yeah. Obesity actually causes over 60 diseases, very serious diseases. And that’s why the term is actually called metabolic surgery because it’s actually proving those metabolic diseases or resolving those metabolic diseases. So, we hear type two diabetes all the time, high blood pressure, sleep apnea, liver disease. But as I said, there are over 60 diseases that obesity causes-

Kerri: Sure, depression too.

Dr. John Oldham: Yeah. Depression, exactly. We don’t, what comes first, depression, obesity, medications that treat obesity causes obesity. So those are the things we have to worry about. Obesity is actually, it is a disease. It’s not going home, eat less and exercise kind of thing. We all have a weight that our body wants to be at. It’s called a metabolic setpoint. So when somebody could weigh 500 pounds or 200 pounds. When they go on a diet, and try to lose weight, their body sees that as abnormal and it’s going to do whatever it can to drive that weight back up to that set point. And that’s why it’s such a high failure rate with diet and exercise. So these procedures are actually changing that set point to a lower set point, to a healthy set point.

Kerri: Got it. It’s really-

Dr. John Oldham: So still tools, there’s no magic procedures out there, but very good tools.

Kerri: Yeah, absolutely. Well, what does the listener need to know about pre-surgery, some of the requirements, considering diet before they get ready for this surgery?

Dr. John Oldham: Yeah, it’s a good question. So we actually like our patients to get as much information as they can. And I think the best place to start out is to attend one of our informational seminars. We have three a month. We do two at the main hospital in Baptist and then one in a hospital in Lagrange. And that’s where we talk about obesity. We go over all the different procedures that we offer and that way, the patients can kind of get a good feel of the understanding of what we’re talking about and the different procedures. And then they’ll fill out this informational packet that we give them, determines if they qualify for surgery. And there are some insurances that don’t cover the surgery, they have an exclusion in the insurance.

Dr. John Oldham: So we discuss that with them. We do self-pay if there’s somebody that does have an exclusion in their insurance and they want to proceed, but once they fill the packet, we’ll contact them, have them come into our office and we call this the intake appointment. And this is where, they’re about five, six hours. So it’s a long visit, but it’s kind of get it all done in one-day thing. They’ll see the dietician, they’ll see the psychologist, they’ll get counseling, they’ll see nurse practitioners. We do BMR testing, which is basal metabolic rate testing. So we do a lot of education on that day. And then once they have that, there are some insurances that require their patient to do a monthly diet visit, three months, four months, six months. Some insurances don’t require it, but most insurances do. And then they’ll come back for the final visit before surgery. That’s when we go in detail about the surgery. We discuss all the possible complications, which are very rare in our hands and then we go to surgery.

Kerri: Okay. Well what are some of the risk factors and disadvantages that we need to know?

Dr. John Oldham: Very, very safe procedure. Again, everything is all done laparoscopic. The biggest concern since we have to cut the stomach, and again we’re going to take about 80% of the stomach out. So instead of having this big football-sized stomach, we have a kind of a large banana sized stomach now. So we are cutting the stomach, so the big concern is a leak. It is a very rare in our hands. It’s less than 1%, it’s less than 0.27% but that’s a possibility since they’re cutting the stomach. Blood clots, another thing that is a concern.

Kerri: Is there a risk of a hernia?

Dr. John Oldham: Incisional hernias are very rare in laparoscopic surgeries because we’re doing four to five little bitty incisions the size of my pinky, so we’re talking very, very small incisions. So the chance of incisional hernias are extremely, extremely rare.

Kerri: How about weight gain over time?

Dr. John Oldham: Yeah, it’s always a question. As I said earlier, these are only tools. There is no magic procedure and you’ll hear us talking about that all the time. We have patients lose 100% of their excess weight, but they’re not meant to do that. They’re meant to get you to your healthy weight. We also have patients that can struggle long term. And that’s why follow-ups are very, very important. We want to see our patients at least once a year for the rest of their life after the first two years. We see patients frequently the first two years but if somebody is struggling or maybe gaining some weight back down the road, that’s when we definitely want to see them back in the office to help them.

Dr. John Oldham: We have different options getting them back on track. We can look at weight loss medications. So there are all kinds of things that we can do. But that’s where the education is. And using the tool correctly, patients will do very well. But the surgery is really meant to get you, lose about 60 to 70% of your excess weight. That’s kind of an average. And that’s the long term. So 70% excess weight loss. If somebody was a hundred pounds overweight, that would be a 70-pound weight loss, 200 pounds overweight, 70% excess weight loss would be 140-pound weight loss. So, but that’s an average and that’s long term. But as I said, we have patients lose 100% of their excess weight, get down to the ideal body weight, but again meant to get you to a healthy weight.

Dr. John Oldham: And it’s sometimes hard to determine what is a success. If somebody lost, only lost 50% of their excess weight, but they get off their diabetic medications or off their blood pressure medications, they’re off their C-PAP medications, it helps with their liver disease, that’s kind of where we-

Kerri: That would be successful.

Dr. John Oldham: Yes, exactly.

Kerri: What can patients expect in terms of surgery?

Dr. John Oldham: So the surgeries are done with a general anesthetic and that’s all laparoscopic surgeries. The gastric sleeve takes about 40 to 45 minutes to do to an overnight stay. So just going home the next morning, as I said, there’s about four to five little bitty incisions. We do this through a video monitor. We have angled cameras that we put inside the abdomen, we insufflate the abdomen with CO2 gas. Again, that’s all with laparoscopic procedures. We go in and we actually resect part of the stomach called the greater curvature. So we’re making this football-sized stomach into kind of a large banana size stomach so that the part of the stomach that we removed is taken out.

Dr. John Oldham: I know a lot of patients, sometimes when they hear the word gastric sleeve where you’re taking that stomach out and it’s permanent. Yes, it is permanent. We can’t put the stomach back in, but this is the size stomach that we need in today’s environment, with our Western diet. We don’t need this big football-size stomach nowadays with our American diet, so I think that if you think of that way, just a smaller stomach kind of, it makes sense. But as I said, stapling the stomach, remove the stomach, 40, 45-minute procedure and overnight stay going home the next morning. Actually we’ll start out with some liquids right after surgery when you go up to your room. The next morning, we kind of have some protein drinks, some broth, things like that then get to go home. We have online information, but we don’t have an online informational seminar at this point. We’re actually working on that.

Kerri: Before we close out, I want to talk about some of the myths and debunking some of these myths for bariatric surgery. One that we’ve heard is that bariatric surgery is dangerous and I’d love to hear your response to that if you’ve heard that from patients or prospective patients.

Dr. John Oldham: Absolutely. Bariatric surgery kind of got a bad name when, as I was saying earlier that it was all done through open procedures and we did see a lot, a lot of bad complications. And again, that was back in the eighties and nineties but now that this is done laparoscopically, it is very, very safe. As I said, complications like bleeding, blood clots, leaks are very rare, less than 1%. Again in our hands, this can be done very, very safely.

Kerri: And it makes sense for a shorter recovery time as well.

Dr. John Oldham: Right, exactly. Exactly. So patients who right after surgery, when it’s done laparoscopically, they’re up on their feet walking right after surgery. We actually have them on a schedule, they’re walking around the nurses’ stations every two hours around the clock, after surgery. And when they go home, the only restriction that we tell them is heavy lifting. And that’s anything over 25 pounds for about two weeks. if somebody wanted to leave the hospital, they can run over to our Baptist Milestone Gym around the corner, hop on a treadmill and go at it if they want to. They’re not going to feel like doing that, but they can do that. So again, we don’t want it to limit their activity.

Kerri: Another myth that we’ve heard is that insurance does not cover the weight loss surgery,

Dr. John Oldham: Right, so insurances do cover the bariatric procedures, but there are some insurances that do have exclusions. And that’s where we can find that out for patients. Or if they have to meet that BMI criteria, the 40 and above without comorbidities or don’t have to have a comorbidity. Or if your BMI 35 to 39.9, you would need some type of, like hypertension, diabetes, sleep apnea, something like that before they would cover it.

Kerri: Okay. How about the myth medications are the best way to treat an obese patient’s medical conditions? Have you heard that one?

Dr. John Oldham: Well, for slightly overweight patients, medications are good. We want all of our patients to at least have tried different weight loss things in the past, that most of our patients have done, diets and medications, things like that. There are five FDA approved medications. We use them in our office and our practice, but it’s usually for a small percent of weight loss, only about 7 or 8% weight loss with these medications. And then usually if the medication is stopped, usually that weight does come back. Obesity is a very, very serious problem. Even somebody just with a body mass index of 30, which is only about 30 pounds overweight, has a 50 to 100% increased risk of dying prematurely compared to a normal weight individual, dying 10 to 15 years earlier than they should. So that’s what we want to change, to make patients healthier, prevent diseases like diabetes, hypertension, and sleep apnea, things like that, and make sure they’re adding years to their life and not dying prematurely.

Kerri: Sure. Thank you for joining us today, Dr. Oldham.

Dr. John Oldham: Thank you.

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