Guest: Dr. Thomas K. Byrne - General and Gastrointestinal Surgery
Host: Dr. Linda Austin – Psychiatrist
Announcer: Welcome to an MUSC Health Podcast.
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Thomas K. Byrne, who is Medical Director of the MUSC Bariatric Surgery Program. Dr. Byrne, bariatric surgery has been around for a number of years and at this point, I understand there are a couple of different ways that surgery is performed here at the Medical University, what are different approaches to that surgery?
Dr. Thomas K. Byrne: There are many different approaches, but there are about four mainstream operations that are done currently in the US. The commonest procedure done in the US is the gastric bypass procedure. Mostly, we do that procedure laparoscopically these days. Occasionally, we have to do it open depending on the patient’s body size and previous operation. The other operation is becoming popular right now and you may see it advertised a lot as the laparoscopic adjustable gastric band, which like as the name suggests is done laparoscopically and is adjustable. Both procedures are restrictive procedures in the sense that the objective of both procedures is to restrict portion sizes.
Dr. Linda Austin: How do you decide who is a candidate for which of those two procedures?
Dr. Thomas K. Byrne: Well, for the most part, the patient decides themselves, and there is much information on the internet and many other places about the differences between the two procedures, how they both work and how the weight loss profile with each procedure is little different. On occasion, we will tell the patient that we don’t think they are suitable, for example, for a band. In some cases, we will tell patients that they are more suitable for a band than they are for a gastric bypass, but for the most part, the patients decide themselves.
Dr. Linda Austin: Now, we have this opportunity. Let’s take it to talk about what the difference is and how patient might think about the pros and cons of each, can you explain that?
Dr. Thomas K. Byrne: Mostly, it depends on how the patients want to lose their weight. So, there are pros and cons to both procedures. The first thing is that with the gastric bypass, the weight loss that occurs, what is considered to be, rapid weight loss phase occurs within the first six months of the surgery. So, if a patient has surgery today, within six months, they will have lost most of the weight they are going to lose, but their weight loss will persist after about a year and a half, may be, and then it will slow down or stop. With a laparoscopic adjustable gastric band, the weight loss is much slower because the band has to be adjusted to get the patient to the exact point where they are feeling restricted, not feeling hungry, and are losing weight; that may take several adjustments of the band, therefore the weight loss is slower. So, it may take a patient three years to lose the same amount of weight with a laparoscopic adjustable gastric band as it will for a patient who has had a gastric bypass in year and a half. So, weight loss profile is different. The advantages of the band over the gastric bypass are that the band is lower in complication rates and the complications that do occur are less catastrophic. Most of the band complications can be taken care of on elective basis. Somebody calls with a band of problem, we will see them in the clinic and if need to re-operate on them more aggressively, it can be done electively. With the gastric bypass if the complication occurs, it’s usually dangerous and life threatening and has to be addressed immediately. Patients who have gastric bypass, if they get out of the hospital and do well over the course of a week or so, then it’s unlikely that they are going to have a catastrophic complication. With a laparoscopic band, complication can occur at anytime such as band slippage or band erosion that can occur years down the road. So, there are differences, differences in the risk level, but also differences in the way the weight is lost. The data that we have so far indicates that with a gastric bypass, patients are likely to lose 10% more overall at end of their weight loss than a band. So with gastric bypass, a patient may lose more weight overall, we think
.Dr. Linda Austin: Certainly many, many pharmaceutical companies are very actively researching medications for weight loss and let’s imagine that in 5 years or 10 years, some great drugs come out for that, are either of these procedures reversible?
Dr. Thomas K. Byrne: The laparoscopic adjustable gastric band is entirely reversible because you can just take the band out. However, we really don’t know because the band may have caused such scarring that despite taking the band out, the patient may still get restriction; we don’t really know that the gastric bypass can be reversed. It’s unusual for us to have to do that and generally, people who have their gastric bypass reversed will put all the weight back on again. So, it’s very rare for either of these procedures to be reversed. The band sometimes will have to be taken out if it erodes into the stomach or if it is causing too much constriction or the various other reasons -- or if the band continues to slip, and in some of the earlier trials that were done at the band removal, occurred may be 10% or 11% of the time. So, it can be taken out and reversed.
Dr. Linda Austin: What are some of the complications of these procedures that you tell patients about?
Dr. Thomas K. Byrne: Well, any morbidly obese patient who comes to the hospital if they have a procedure, the risk of a blood clot or a pulmonary embolus, blood clots of the lung; that’s probably the biggest killer in either procedure nationwide that can happen to any patient who comes in the hospital, but it’s particularly more prevalent in morbidly obese people. The complications that we worry about with a gastric bypass are leakage from some of the hookups that we do inside the abdomen, we re-route the pieces of intestine here and there. The objective of the surgery is to create a small pouch, divide the stomach in two parts with a small pouch at the top and rest of the stomach below, and then we would bring pieces of small intestine up to the pouch and basically hook it to pouch. If that hookup comes apart and patient leaks, then they will get an abscess inside their abdomen and that could be potentially life threatening. Other problems can that occur of course are bleeding from the staple lines, bile obstruction, wound infections, and so on; they are the common complications with gastric bypass. With a Lap-band, the commonest complication is the band slips out of the position we have putted in, that can occur about 25% of the time. If that happens, then the patient will need another operation to put it back where it is supposed to be. The other complications include erosion of the band into the stomach and also a problem with the port that we inject. The ports can become infected or it can flip around or move out in a position and so on.
Dr. Linda Austin: All of those sound like potentially scary complications. I think what balances it on the other side are the extreme complications of not having surgery that is staying morbidly obese, and what are some of those problems?
Dr. Thomas K. Byrne: Well, the overall complication rate for surgery, taking all commerce is about 10%, that is for the most minor complication such as a urinary tract infection from putting a Foley catheter in at the time of surgery to a disastrous complication such as a leak or a band erosion or the like. So, overall, 10% of patients will have a complication. That means a 90% of patients will come in the hospital and go out two days later and do absolutely fine. Now, a lot of these patients, who have come in, who are diabetics and hypertensives, the data that we have currently indicate that 85% of type 2 diabetics are cured with bariatric surgery. So, we can cure type 2 diabetes in morbidly obese people and 92% are improved or cured, so that’s phenomenal, particularly since we have an epidemic of diabetes in this State. About 78% of people who have got hypertension are cured of their hypertension and get off the medications and about 96% of people with sleep apnea syndrome are completely cured within about three months. So, if you look at the advantages of these procedures is the weight loss in the first six months, for example, after gastric bypass as the weight loss begins to increase, all the medical problems begin to disappear and the patient’s list of medication drops dramatically to where they are just taking a calcium tablet and a vitamin B12 tablet everyday.
Dr. Linda Austin: That must be incredibly exciting for you to see.
Dr. Thomas K. Byrne: It’s very exciting, very gratifying, and also tremendous to see how patient’s attitudes towards their health and towards life improve when they finally have the opportunity to get this monkey off their back, but one of the things that we are very careful to explain to patients is that what we are going to do in our program is provide them with a tool to help them to lose weight; how they choose to use the tool is up to them. We will provide them with all the support systems they need but at the end of the day, they still have to use the tool appropriately. Some people do fantastic with it; in fact, probably about 85% do great and 15% of people will fall off the wagon to some extent and will eat the wrong types of food, not exercise, and so on and so forth, and put some of the weight back on. In fact, we have had a few people put all of the weight back on, but we know why it has happened, because they haven’t conquered the problem that caused them to put the weight on the first place and haven’t used the tool appropriately.
Dr. Linda Austin: Dr. Byrne, thank you very much for talking with us today.
Dr. Thomas K. Byrne: Thank you.
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