Dr. Misra has performed more than 5,000 bariatric, advanced laparoscopic and endoscopic surgical procedures and has presented research findings at numerous national and international meetings on advanced laparoscopic techniques and metabolic surgery. She is a surgeon at the Weight Loss Center at the Cedars-Sinai Medical Center. Prior to joining Cedars-Sinai, Dr. Misra was a surgeon and an assistant professor at Canada’s McMaster University. She talks about how there are good candidates and great candidates for surgery and then there are patients that are not prepared for surgery at that moment in time. She discusses the pros and cons of all three bariatric surgical procedures and takes the viewer through the post-surgical side effects associated with each.
My name is Dr. Mona Misra. I am a board certified general surgeon. Medical school was in Canada. I did my residency and general surgery training also in Canada. And then I came to Los Angeles Cedars-Sinai for my fellowship training in bariatric surgery, or weight loss surgery. And I've been in practice for a little over 10 years now.
The World Health Organization actually designated obesity as a disease since 1991 so we have known for a very long time that obesity is a disease and should be treated as a disease. Not only are we seeing more and more patients that are overweight or obese but probably 65 percent of the population is obese or overweight but this is not a problem that's going away. We're seeing it in teenagers and children, so this is actually something's that getting worse over time.
I wouldn't consider eating an addiction. I think it can be but really I think the problem with obesity is multi-factorial. There's many reasons that people become obese, whether it's genetics, whether it's a coping mechanism, so behavioral; people eat when they're happy, sad, bored, stressed, all these reasons. It's a very social event so it's very hard to get away from it. There's socio-economic reasons that people become obese, psychological reasons, so we actually have so many complex factors that really have to be addressed to deal with the issue of obesity. It could be a social issue. It could be an injury, so they hurt their back, or they hurt their knee, so then they started putting on weight.
So if there's behaviors that need to be changed, if it's a coping mechanism, we do actually get them to meet with our psychologist and find out different coping mechanisms that will be better for them. If it's just the types of foods that they eat and they need better guidance on what they should be eating, they definitely meet with the dietician, as well, so they can get better educated on what are healthy foods, what are proper portion sizes
So BMI or body mass index, the way that we calculate it is taking someone's height and weight and then doing a calculation that creates a number. And we just use that to be able to give a reference when we're talking about weight, what exactly that means, because a gentleman that's 6'2" and 200 pounds is very different than a female who's 5' and 200 pounds. Anyone whose BMI is 30 to 35 that's where they're considered obese. Thirty-five and higher, with a medical problem that's related to obesity, like diabetes, high blood pressure, sleep apnea, or a BMI of 40 or higher with no medical problems, that's considered morbidly obese. So like I mentioned cardiovascular disease, hypertension, diabetes, and sleep apnea. Cancer is even at an increased risk. So there are so many issues that people need to be aware that they're at risk of developing as their weight or BMI increases.
I would say that there are good candidates and great candidates for surgery and then there are patients who are not ready for surgery at that moment in time. And so if they're thinking that this is going to be magical and they can eat whatever they want and, you know, the surgery is just going to deal with all the problems in their life, that's not a healthy way of beginning this process.
There is always a work-up that's required before surgery to make sure you're safe to move ahead with surgery, but also there is usually insurance companies wanting a three-month or six-month of failed medical weight loss or supervised medical weight loss showing that you are unable to lose the weight with diet and exercise alone. They want you to at least attempt with diet and exercise to lose the weight. And many of these patients have done this their entire lives. They've been on a million diets. Unfortunately most patients are unable to lose the weight and keep it off long-term with only diet and exercise, which is why we move forward with surgery.
So, there are three main procedures out there: the lap band, the laparoscopic sleeve gastrectomy, and the laparoscopic gastric bypass. All three are good options. It's just a matter of choosing the right one for the patient.
The lap band basically is a device that we place on the upper part of the stomach. It has a silicone balloon on the inside and so what happens is that as you lose weight you lose weight inside and outside at the same time. The band is connected to a little port that we place underneath the skin on top of the muscles on your abdominal wall. And so every time you're losing weight, as this band kind of gets looser, we need to add a little bit of fluid, saline or salt water, into that balloon to kind of tighten it up. The band is basically a restrictive device. It really slows down the meal that you're having, so normal size plates; it takes 20 minutes to eat. You can eat maybe a quarter of that in about 30 to 40 minutes. So it totally slows you down, and it just gives more time for those signals to be sent to the brain to say, yep, I'm full, stop eating. You're able to actually eat smaller portions of food and actually be satisfied.
People would describe it as more high maintenance compared to the other two because you are needing to come in for adjustments or tightening up the band as you're losing the weight. This is typically a two- to three-year process. People are losing about 60 percent of their excess weight, so a hundred pounds; lose about 60 pounds in about that two- to three-year mark.
The lap band surgery takes about 45 minutes to an hour to perform and it's done as an outpatient. Usually people are able to go home the same day. It can be done in a surgery center. Depending on their health, if they're having a lot of medical issues that we're concerned about, we may need to keep them overnight and it may need to be done in a hospital. But on average patients are usually able to be done and go home after a couple of hours.
The main things that patients have to understand is that they really have to choose their food well and they have to go slow, so initially as they are learning the process they may have some nausea and vomiting and heartburn and all these types of symptoms because they're still learning to chew their food well and go really slow. Certain things they'll never be able to eat again like doughy bread; it's really tough to go down; it's just not going to be able to be chewed well. Steak, that's tough like a chair; that's not going to go down. Maybe really tiny bites of really tender filet mignon, they might get that down, but they really need to chew it well. Carbonated drinks, for all the procedures, really, really difficult, really uncomfortable; usually that's out of the diet.
Usually the recovery for something like the lap band is a week before people are able to go back to work. The lap band does have about a 20% lifetime re-operation rate so it is something to keep in mind. So if you're trying to lose a significant amount of weight usually people don't move towards the lap band. It's doable but usually you're looking at the other options when you're having a significant weight to lose.
The laparoscopic gastric bypass again has always been considered the gold standard. We know that it's been around for about over 30 years cause it started out as an open procedure and then moved toward laparoscopic as that technology developed. People lose weight, usually about 80 percent of their excess weight, so 100 pounds, about 80 pounds in about a year to a year-and-a-half, so it's pretty quick.
What we're doing is basically taking their football-size stomach and creating a small little stomach about the size of a golf ball, and then we're bypassing about a hundred centimeters of their small bowel and then dividing that small bowel and bringing it up to that little pouch. So it's kind of working three ways. One, you have a tiny little stomach so you're full with less food. Two, we're bypassing a lot of your small bowel and that's where you absorb your vitamins, minerals, proteins and calories. The basic understanding is that because you're small bowel is where you're absorbing all your calories, if you're bypassing some of it; you're not absorbing all the calories of the food that you're eating. So if you're eating a 2,000-calorie meal, you won't absorb all those calories. You end up losing weight that way.
And then there's a significant hormonal component that makes people not as hungry. They just don't want to eat the foods that they covet, the foods that they used to eat before; and they're able to lose the weight. Bypass surgery usually takes about an hour and a half to two hours to perform. This needs to be done in a hospital setting. Usually you're in hospital for about two days. Usually the recovery for something like the lap band is a week before people are able to go back to work. The gastric bypass we're usually looking at about two weeks, and this for a desk job. Heavy lifting, anything really strenuous, you're kind of looking at four to six weeks.
It is a safe operation but there is more risk involved with the bypass compared to the other two just because of all of the cutting and joining that we have because we worry about things like leaks, for example, which is where when you're making kind of like pipe tubing and it needs to be an airtight, watertight seal, we worry about a little fluid leaking out that could cause a serious infection. And that's one of the major risks about the bypass.
The laparoscopic sleeve gastrectomy is a great operation. What we're doing is taking your football-size stomach and cutting away about 75 percent of it and leaving you with a long, skinny tube, kind of like a banana. So it's working two ways. One, you have a smaller stomach so you're full with less food. You still have to chew your food well and go slow; just like the other operations. The second benefit is that a big portion of the stomach that we're cutting and getting rid of, you don't need it; you will likely never need it; but it produces the hormone called ghrelin, which is one of our hunger hormones. By getting rid of it, you're not as hungry so it's using nerves and hormones to make you feel full with less food, and because of that, weight loss is a little bit easier
And typically people are losing about 70 to 80 percent of their excess weight, so a hundred pounds, 70 to 80 pounds, in about a year to a year-and-a-half, so it's pretty quick. It is a little bit safer than a bypass just because there isn't any joinings; there's just one big long straight line; but again we are worrying about leaks, but there's a pretty low chance of it happening.
We find that patients do well because you don't really have the same types of side effects that you do with something like the bypass in that you don't have something called dumping syndrome. So, many patients kind of move towards the sleeve because it's a little bit safer; you're not getting those kind of side effects and you're losing weight almost as fast as the bypass so there's a lot of pluses to the sleeve.
I think it's important for patients to understand that this is still surgery and they need to have proper expectations of what's going to happen afterwards, so we do prepare them well before surgery with a lot of information, but afterwards there is pain, so expect that you're going to need painkillers. For the sleeve gastric we keep you overnight. Usually you get to go home the next day. You need those painkillers, usually as an IV, for the first night. The first two days after surgery I just tell my patients, take that pain meds regularly, stay on top of it, because you're really not going to feel well. I usually tell them you're not going to like me very much for the first two days but you're going to love me after that. The few days after that you're going to need the painkiller every once in a while but it's not too bad. It's just every once in a while but that first three days can be pretty rough.
So, typically dumping syndrome, which is a side effect of the gastric bypass surgery, is something that is a significant problem if you're not aware of it and understand that you need to follow the rules to not have the dumping syndrome symptoms. So what I mean by that is carbohydrate-rich foods. If you're told don't eat sugar or make sure it's very low sugar, don't eat sugar because you're going to feel terrible from the dumping syndrome afterwards. There's a way to prevent it; don't do what we're telling you not to do.
The other side effects, because we don't see dumping syndrome with the lap band or the gastrectomy, looking at other side effects, hair loss is the common one that people talk about. With hair loss, it's typically seen with rapid weight loss, and we do make sure that you're on your multivitamins, and we like you on supplements, things like Biotin do help prevent it but not completely. A lot of other people still have some hair loss. Typically after rapid weight loss if you're losing 50 pounds in six months hair grows in phases and what happens is your body kind of realizes that the other organs are very important. You've suddenly lost 50 pounds; it doesn't totally understand why. So what's happening is it says hair is the least important out of everything else that's going on and functioning here and it sort of lets it go a little bit; you actually end up getting a little bit of hair loss because of that. For some people it's pretty significant. Over time, though, it typically does come back. Maybe 80, 90 percent of what it was before. We usually see it early on and it’s also why when we're having rapid weight loss surgery, like the sleeve gastrectomy or the gastric bypass, we are checking your vitamin and mineral level.
We want to make sure that you are taking in the right vitamins and minerals and enough protein and drink enough water and do all the things that you need to do to make sure you're as healthy as possible as you're losing your weight. Dehydration is a common thing that people talk about because it's not possible to drink very quickly anymore. So everything has to be slow, whether it's a band; whether it's a sleeve; whether it's a bypass. So you're going to sip water and any zero calorie drink slowly throughout the day. If you're trying to drink 64 ounces of water a day, that's a lot of water to get down, so you need to carry water bottles everywhere you go.
Typically, what we tell patients is do not drink anything at the same time as your meal, I usually say 15 to 20 minutes before a meal and after a meal we don't really want you drinking anything. We find that patients get really full if they drink at the same time as their meal so if you're eating a very small portion of food and getting completely satisfied, add water to that you're getting a lot less protein that you need to get. Males want to get 80 to 90 grams of protein a day. Females at least 50 to 60 grams of protein a day. That's a lot to get down, and if in your meal you're drinking at the same time you're not going to get the nutrients and the food that I want you to be eating.
Usually we find the symptoms of the nausea and the constipation and diarrhea and all those types of things, gassy, bloaty, those symptoms, they're usually are earlier on after surgery. More common with something like the bypass because it is such a big operation and changes in what we're doing with the way things are absorbed in your body, but for all the operations there's a potential because we're inside there; we're doing things to your body. If you're finding that you're getting sort of looser bowel movements, get a lot of fiber in your diet so that it's like Metamucil, Benefiber, any of those fiber supplements, there's chewy, gummy kind of stuff; whatever you can tolerate because the fiber will help soak up some of that water and then they won't have as much diarrhea.
Some patients are concerned about their skin after the weight loss, and the excess skin, and some insurance companies cover the excess skin that hangs over if it's causing, you know, infections and redness underneath cause it's hanging over so much, and they will pay for that part of the operation. Not all insurance plans cover it. Some patients with exercise are able to kind of bring it in enough that it's not hanging over; it's not super bothersome to them; and they have so many great clothing devices out there that they're able to hide it really well.
So it's really a very personal choice. The excess skin depends on age and genetics and the elastin in the tissues and exercising does help but it's not a hundred percent. Usually if you're already having a lot of hanging over you are going to continue to have that skin hanging over, but for some patients it's mainly just protruding out and when they lose the weight it kind of comes back in. It's never tight, tight. But it's enough that it's not really bothersome to them so they don't care.
This is an issue to think about but I don't think it's something to completely focus everything on because the reason why we're doing this operation is to extend years of life and quality of life, so if we're adding 8 to 14 years to someone's life and they're no longer taking a handful of medications every morning for their diabetes, high blood pressure, high cholesterol and we're preventing that heart attack and stroke that were going to happen down the line, I don't think they care about a little bit of extra skin.
What we're finding and actually the reason why some patients come in for weight-loss surgery is the effect that it does have on female hormones and makes them actually more fertile. So many patients have difficulty getting pregnant. By losing their weight, they become more fertile. So there is even one more reason why many patients look into weight-loss surgery.
And because of that even if you're closer to menopause and you don't think there's any chance you can get pregnant, we warn them very seriously that they need to be on a birth control for the first year at least after surgery. Depending on the type of surgery, it's almost a year and a half to two years for bypass, but for sleeve and for band, we're looking at least a year, a year and a half, we want you on very strict birth control because we've had 42-year-olds become pregnant, and they weren't planning on it. Losing that weight not only makes you more fertile but it makes the whole pregnancy so much safer. So gestational diabetes and high blood pressure and having 12-pound babies, I mean, that's bad for mom and baby; it's higher risk. And so what we're able to do is to bring you into normal risk again; it's so much better for the mom and the baby.
I've seen many patients who have come in, younger patients, 20, 21-year-olds, 18-year-olds, who have come in saying I've been on diets since I was 8 years old; I am so morbidly obese; I need to do something about my weight. And as long as they have an understanding, again, about the lifestyle modification and behavior changes that they need to change and embrace, they're great candidates for surgery so the times that we're a little bit more cautious is below 18 years of age, and that's more when people are doing it under research protocol and that type of thing. Those patients have a complete understanding of what they need to do and that they need to do it forever and are ready to do that the most important thing they can do is get information.
I think it's important for patients to do well to know that they always have someone who's going to be there for them. I tell them when I meet with them that I'm going to cheer you on when you're doing good things but I'm also going to yell at you when you're doing bad. That's my job. You know, I'm the one that's going to be honest and real with you and you may fall off the wagon and kind of go in a direction you're not supposed to go but you always know that I'm going to help you get back on track. You need to come back to your surgeon or whoever you're physician is that's following you and make sure that they are keeping you on that commitment and goal of lifetime and behavior modifications.