If you or someone you know lives with obesity, you understand the struggles of endless weight loss programs that have shown no results, exhaustion from small tasks and the increase of various health risks due to weight.
The surgeons at BMC have performed thousands of successful surgeries and BMC's Bariatric Surgical Program is recognized as a Center of Excellence by the American College of Surgeons.
In this segment, Donald Hess, MD, Director, Bariatric Surgery Program at BMC, discusses how weight loss surgery can change your life, help you lose weight and provide you with an excellent tool for managing your weight and weight related health problems.
Donald Hess, MD
Dr. Hess is the Director of the Bariatric Surgery (Weight Loss Surgery) program at BMC. He leads a team of three other surgeons, and together they have performed thousands of successful surgeries. BMC's program is recognized as a Center of Excellence by the American College of Surgeons.
Dr. Hess completed his medical degree at the University of Rochester School of Medicine. In addition to bariatric surgery, his clinical interests include general surgery, minimally invasive surgery, and hernia repair.
Melanie Cole (Host): If you or someone you know lives with obesity you understand the struggles of endless weight loss programs that have shown no results, exhaustion from small tasks, and the increase of various health risks that are due to being that overweight. My guest today is Dr. Donald Hess. He’s the Director of the Bariatric Surgery Program at Boston Medical Center. Welcome to the show, Dr. Hess. As far as bariatric surgery – people hear these words they hear weight loss surgery – explain a little bit about what these procedures are as a tool to help people in their weight loss endeavors.
Dr. Donald Hess (Guest): Sure, Melanie. We see a lot of patients who have failed what we call conservative methods. They’ve tried diets. They’ve tried many other methods. They’ve met with nutritionists and dieticians, and then they consider surgery. The two most common procedures that we perform are the laparoscopic gastric bypass and the laparoscopic sleeve gastrectomy. All weight loss surgery is done laparoscopically, which gives the patient a very quick recovery time. The typical patient we see for these procedures is somebody that we would say meets the NIH criteria. The National Institutes of Health developed some guidelines years ago, which means the patient would need a BMI greater than 40. For example, a five-foot, six-inch patient would need to weigh 250 pounds, or a five-foot, six-inch patient needs to weigh 190 pounds if they have some weight-related problems like diabetes, hypertension, or sleep apnea. A lot of our patients undergo weight loss surgery not just to lose weight, but also to fix some fairly life-threatening medical problems. Oh, and one other thing. I’d like to mention that bariatric surgery is covered by every health plan in Massachusetts, so whatever health plan you have, whether it’s one of the state-run programs, private insurance, Massachusetts residents have bariatric surgery as a covered service.
Melanie: Let’s speak about the process itself of getting to be a candidate – or a potential candidate for bariatric surgery. What’s involved for the patient? Is there psychological counseling involved? How do you advise them that this is a big deal, and what they should be looking for and forward to?
Dr. Hess: Oh, absolutely. One thing that we instituted a number of years ago is an information session. It’s something that you would when you contact our office – we have a number of them during the week, Monday evenings, Friday midday, and also one for Spanish-speaking patients on Fridays, as well. That information session will go over all the procedures, the risks, the benefits; it will discuss the procedures and specific health issues that they improve. For example, gastric bypass is better for diabetes than some of the other operations, so we talk about that. Somebody that might have reflux or heartburn, one operation might be better than another. Once they do that, then the first step in the process is meeting with the surgeon. Everybody will get an individual appointment with a surgeon where we look at each candidate, go over their health history, their dietary attempts, and determine whether we think they’re a good candidate for the operation. Once that’s the case, we have a very good multidisciplinary program. We have bariatric-specific dieticians. We have a number of medical nutritionists. Now, these are MDs and NPs that work only with obesity. They help patients change their diets ahead of time, help them lose a little weight before surgery to make it a safer procedure, and help prepare them for the operation. Everybody is required to undergo a psychological evaluation. Most of the time, this is just perfunctory, but of course, we want to make sure that people’s problems with obesity aren’t stemming from some underlying psychiatric problem that hasn’t been treated. Often, the psychiatric evaluation won’t stop anybody from having surgery, but sometimes we suggest that they get some counseling ahead of time to help any problem that has yet to be treated.
Melanie: There’s so much information on this, Dr. Hess. We could really speak for quite a long time, but what do you want them to know before the procedure, or what would you like patients to do before the procedure? Should they be trying to lose weight? Should they be exercising quite a bit? What would you like them to do before hand?
Dr. Hess: Well, most of the people who we see have been contemplating bariatric surgery for a number of years. They’ve really exhausted the conservative methods. What we want them to do -- once the surgeon sees them we want them to listen to the Dieticians, learn about the diet after surgery, really become educated about the procedure and about the lifestyle changes necessary. We also want them to meet with the Medical Nutritionist and try to obtain a modest weight loss. I think the most important thing for our patients is to be well-educated about the procedure – even down to the hospitalization will be two days, they will be on a high-protein, liquid diet at the beginning. We want them to get support service – support mechanisms in place, family members or friends that can help them through this early period. We want them to be prepared and to be successful.
Melanie: So then, the procedures themselves, the gastric sleeve and the gastric bypass, explain just a little bit about the differences.
Dr. Hess: Okay. We’ve been doing the gastric bypass since the 60s in the United States. That operation is where we make a very small stomach, and then reroute the beginning of the small intestine to allow the food to bypass, not just the stomach, but the first part of the small intestine. I think it was initially a surprise to the surgeons that performed this operation that it had a tremendous effect on diabetes because of bypassing the initial part of the small intestine. The newer operation is the sleeve gastrectomy. We don’t reroute the intestines at all. We just take the stomach, and we make it long, and narrow. A lot of people say, “Oh, my stomach will become shaped like a banana.” We do this by excising 85% of the stomach. Interestingly, diabetes gets better as well with this operation. Some of the hormones that are responsible for diabetes are produced in the part of the stomach that we remove, and because of this, we do see improvement in a lot of the medical conditions associated with obesity as well.
Melanie: What is life like after the surgery for this bariatric patient? What can they start eating at the beginning? How does this change their life? And as I said in the intro, Dr. Hess, it’s a tool. It’s not the answer, but it is a tool, so what is it like for them afterward?
Dr. Hess: The most interesting thing that we see as weight loss surgeons is the patient’s hunger is gone for the first six to nine months after surgery. I think when patients think about, “Oh, the surgeon is going to be making my stomach very small or very narrow. I’m not going to be able to eat a lot.” I think their big fear is that they’ll be hungry, they’ll want to eat, or they’ll feel deprived. That, interestingly, is not the case at all. They do not want sweet foods anymore. The patients’ tastes change quite a bit. We recommend the high-protein, high complex carbohydrate diet, and that, now, matches their desires.
Initially, we have them on a high-protein, liquid diet. We then convert them to soft solids, and then after six weeks, we open it up with a lot of education. There are some foods, because of the small – the narrow sleeve or the small stomach with the gastric bypass that never go down well for mechanical reasons. These are bread that’s not toasted, pasta, rice, or very fibrous red meat, none of that goes down well. Besides that, their diet is relatively normal, chicken, fish, vegetables. We have them eat their protein first when they eat a meal, then go to the vegetables, and then perhaps the starches, but we feel that starches are not necessary. In general, they’re eating very healthy, what would appear to be a very normal diet, many months after surgery.
Melanie: What about supplementation for vitamins and minerals?
Dr. Hess: Yep, so we recommend that everybody – if you’re going to sign up for one of these operations, you have to know that there’s an incidence -- in both of them -- of iron deficiency, as well as B12 deficiency. For that, we recommend everybody has a multivitamin with iron, as well as a B12 supplement. The good news is, the liquid B12 supplement now can bring everybody’s B12 level not just to normal, but even above normal when we check it after surgery. We do check everybody’s vitamin and mineral levels at three, six, nine months, at a year, and then yearly thereafter, just to make sure things are going well. The additional thing that we recommend with the gastric bypass is a calcium citrate supplement. This is because calcium is absorbed in the part of the small intestine that is bypassed when we do the gastric bypass. The one misconception is that patients who have the sleeve will not need any vitamin or mineral supplementation, but patients with the sleeve are also at risk for iron and B12 deficiency. Some of the stomach acid is no longer secreted, which helps iron be absorbed, and one of the proteins that help B12 get absorbed is not produced as much in the sleeve.
Melanie: And what about fluid intake, Dr. Hess, because this is a very important part. Dehydration can happen pretty quickly and be a cause of readmission to the hospital. What do you tell them about hydrating?
Dr. Hess: It is our number one cause for readmission. It’s a little more common with the gastric bypass than the sleeve gastrectomy. We want everybody to get in at least 60 ounces of fluid. One of the problems is if people get behind on their fluids – obviously, their stomach is small, the sleeve is narrow, it’s hard for them to catch up. Interestingly, dehydration can cause nausea, and nausea makes people less likely to drink. We do have patients that, if they don’t keep up with their fluid, they go into a bit of a spiral. The good news is it’s easily fixed. They come into the doctor’s office or the Emergency Room, they get a few liters of IV fluid, they feel much better, and then they’re able to keep up with their fluids, but really, it is a very important thing. One thing that, when we do bariatric surgery, it’s a very well-monitored procedure. It’s one of the only procedures where we have a national database, all of our information goes into it. We receive reports every six months from our governing body, telling us how we’re doing compared to our colleagues, so if your readmission rate is a little bit high, they will let you know and then you’ll take steps to decrease it. I think everybody has learned a lot from this database, and because of it, bariatric surgery is incredibly safe.
Melanie: Wrap it up for us, what would you like the listeners to know about bariatric surgery at Boston Medical Center, and what you want them to think about if they are considering this type of surgery for themselves or a loved one?
Dr. Hess: The first thing they would want to know is we have been a Center of Excellence since those designations had been given many years ago. Not only are the surgeons very well-trained, but the operating room staff and the nurses on the floor are very familiar with bariatric surgery patients. We do roughly four to five hundred weight loss surgeries here a year, so if a person decides to come to Boston Medical Center, they’re coming to a very experienced team. I think the other thing you need to know is if you’ve been thinking about weight loss surgery – if you are overweight and have some health-related conditions, contacting our office is not a commitment. The first thing is an information session where you will learn a lot about the different procedures. You can ask questions directly of the surgeon at that point, and then if you feel comfortable, you can go on and make an appointment. But certainly, there is no risk in contacting our office to learn a little bit more about the procedures.
Melanie: Thank you so much, Dr. Hess, for being with us today. You’re listening to Boston Med Talks with Boston Medical Center, and for more information, you can go to BMC.org, that’s BMC.org. This is Melanie Cole. Thanks, so much for listening.