April 25, 2024 • 28 mins
Discover the transformative power of bariatric surgery with Cleveland Clinic's Dr. Sara Monfared in a conversation that could forever alter your view of obesity and its treatment. Dr. Monfared passionately articulates her path to specializing in this life-changing field, emphasizing the urgent need to reframe obesity as a chronic disease rather than a personal failing. By intertwining her personal motivations with professional expertise, she illuminates how bariatric surgery isn't just about weight loss—it's a proactive strike against cancer, heart disease, and more. Our talk sheds light on the imperative for medical care to evolve, placing preventive obesity treatments alongside routine health screenings.
Peek behind the curtain of bariatric surgery with us as we scrutinize the intricacies of various procedures tailored to individual needs. Dr. Monfared walks us through the cutting-edge, such as endoscopic outlet reduction, while addressing the challenges post-surgery patients face, such as weight regain. Her insights aim to dispel the stigma that shrouds this topic, reinforcing the message that setbacks are not reflective of personal failings but rather a call for innovative, minimally invasive solutions that cater to each unique journey.
As our episode reaches its conclusion, we rally for the cause of broadening bariatric surgery access and delve into the necessity of persistent research to secure insurance coverage for state-of-the-art treatments. Dr. Monfared's analysis of the shifting perceptions around endoscopic sleeve procedures, along with the evolution of gastric bypass surgery, offers a beacon of hope for those navigating these waters. We wrap up by inviting listeners to join our vibrant online community, where shared experiences and knowledge merge to support and enlighten anyone touched by the topic of bariatric surgery.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to Core Bariatrics Podcast hosted by
Bariatric Surgeon Dr MariaIliakova and TMA LaCose,
bariatric Coordinator and apatient herself.
Our goal is building andelevating our community.
The Core Bariatric Podcast doesnot offer medical advice,
diagnosis or treatment.
On this podcast, we aim toshare stories, support and
(00:22):
insight into the world beyondthe clinic.
Let's get into it.
Speaker 2 (00:26):
Today we have with us a personal friend of mine who
did medical school at UMKC myStopping Grounds 2, residency at
Indiana University, fellowshipat the University of Texas
Health Science Center at Houstonand is now a Bariatric Surgeon
at Cleveland Clinic.
Let's please welcome with me DrSarah Monfred.
Speaker 1 (00:45):
Hello, sarah, hi, thanks for being here.
Speaker 3 (00:48):
Thank you for having me.
Speaker 1 (00:49):
All right.
So let's just jump right intoit why you got into Bariatric
Surgery and how you got thereand just dive right in.
Speaker 3 (00:58):
Yeah.
So from medical school I justhad an idea I wanted to do
surgery and general surgery wasmy path.
But then when I was inresidency it's interesting, we
all like love to operate andyou're like, how do I pick which
type of career?
So I am a little bit like, oh,I went with things that annoyed
me a little bit less than likeother surgeries, like
(01:20):
positioning.
I hated difficult positioningin the operating room and I was
like, oh, this is nice Arms out.
So a lot of it was just liketechnical, like this is the kind
of career I want to do, this isthe surgery.
But then the other half of itwas the patients I like to treat
obesity because I think itdeals with a million other
things like cancer and heartdisease and lung diseases.
(01:42):
During COVID we realized thatwas a cause of a lot of things.
So I was like, all right, thisis something preventative
medicine essentially.
And then just my own experiencewith weight up and down and I
was like, okay, I can relate tomy patients.
So those kind of were thereasons I headed towards
bariatrics.
Speaker 2 (02:01):
You mentioned preventative medicine and I
really am curious about that,because I think that one of the
things people don't necessarilyrealize is this is one of the
only surgeries that can serve toprevent the worsening of
disease or the development ofdisease.
Can you talk a little bit moreabout why that resonated for you
?
Speaker 3 (02:17):
Yeah, absolutely.
We talk about colonoscopies andhow they're like top reason of
decreasing colon cancer andeverything else smoking, all
this stuff that we're like, oh,we got to get ahead of it, get
your mammos.
And so, like I was like, why istreating obesity?
This is, in my opinion, thenumber one preventative medicine
.
It causes increased risk forbreast and colon cancer.
Obesity does so.
(02:38):
Treating that will help treatthe cancer and then treating
obesity is going to help youhave less heart attacks, less
stroke, all this stuff.
So to me I was like it's, in myopinion, the number one
preventative medicine.
And so, yeah, it was like,whether it's surgery or whatever
it might be, we have to treatthis disease and it is a chronic
disease, so it's not one ofthose where you can just be like
(03:00):
, oh it's one and done.
It's something people live withlifelong.
Speaker 2 (03:05):
In that preventative medicine vein.
Do you think that there'senough public awareness of that
or there's enough awarenessamongst other healthcare
providers that that can actuallyoccur through these surgeries?
Speaker 3 (03:16):
I think there is some awareness in most primary cares
and I think most physicianswhen they see someone who you
know, they tell them like oh,losing weight helps with
whatever they see a cardiologist.
Or like losing weight helps,but as far as still getting the
referrals and still sending themto bariatric surgery, I do
think we do struggle a littlebit because you guys have
mentioned this before we'restill telling people or you
(03:38):
don't have enough willpower.
So even amongst providers,we're still going.
Oh, if you just have a littlebit more willpower, you'll lose
weight, as opposed to actuallyreferring them to an obesity
medicine or bariatric center.
Speaker 2 (03:53):
Yeah, I'm always shocked by that.
It's oh, of course.
This person hasn't been tryingfor their entire life to do this
themselves and hasn't beenstruggling with it forever.
Speaker 3 (04:02):
And you would think, like I said, if you have your 40
and a female and you get yourmammogram, why not?
Hey, your BMI is above 35.
Why not see the specialist?
Whether you get anythingsurgery, medications, anything
why not?
Why is that not part of thepreventative things that should
be checkmarked?
Speaker 2 (04:21):
Okay, that's pretty interesting.
So talk a little bit more aboutwhat that would look like.
And let's say you could wave amagic wand and you can make that
happen.
What would that look like at 40for every woman?
Speaker 3 (04:30):
Yeah, I think that would be.
I don't want to put an age onit because that would be
difficult, but definitely, likewe tell everyone now 45, you've
hit 45, you're due for acolonoscopy or colagard, and
whoever the physician is or theprovider is goes.
This is a checkbox you got todo.
This is preventative.
Same thing, like I said, withmammogram.
So, yeah, I don't know what age, but in my opinion there should
(04:53):
be in the primary care setting.
So I would say, like your BMIis above 35.
I would like to refer you to aphysician.
You can discuss this and it's.
It doesn't.
Again, does not have to be like, oh, you have to have surgery
or even those discussionsbeforehand, but your BMI is 35.
Just have those discussions andit might mean like just an
office visit or a virtual visit,and I think that would be, and
(05:16):
most of these are also coveredby insurance, like we don't have
issues covering office visits.
Speaker 1 (05:21):
I think that would be such a good idea and I think if
people learned.
I think education aroundbariatric surgery and just
medications and stuff like thatis limited, because I think a
lot of this is newer than,obviously, colonoscopies and
stuff.
So I do think that education ishuge.
So if someone just went into,if my primary care doctor told
(05:44):
me to go to a bariatricsurgeon's office just to discuss
things sooner in life, I wouldhave been more educated and
maybe could have had surgeryearlier or been able to battle
things earlier.
So then it wasn't such I needto do this now.
It's a.
I want to do this now toprevent my high blood pressure.
I want to do this now toprevent complications with my
(06:05):
pregnancy.
Yeah, I like the way you lookat that for sure, and I think
that's where we should go forsure.
Speaker 2 (06:11):
Yeah, I think that's a pretty neat approach.
I agree, because when we talkabout preventative medicine,
we're really trying to fix theproblem before it happens.
So make sure people, like Tanysaid, have healthier pregnancies
before they get preeclampsia orgestational diabetes.
Make sure people never developdiabetes in the first place or
develop the high blood pressurewhich people are much, much
earlier now in the past coupleof decades.
(06:32):
So that's really interesting tome.
To just consider obesity carelike screenings, just like
colonoscopies or mammograms,that's a pretty, I think,
innovative approach.
Sarah, that's really cool.
Speaker 3 (06:43):
Yeah, I wish it.
Yeah, it's definitely a dreamof mine.
And I think the other thing is,like Maria will know, I hate
when I get a patient who'salready has so many
comorbidities and they're such ahigh risk and it's like we
could have done this 10 yearsago.
And so that's the other keything.
I think, especially with ouryounger patients and their 20s,
they're like oh, you're just inyour 20s, you can do it and I
(07:05):
think in your 20s and stuff likefor me, I think changing those
lifestyle habits definitely areeasy.
Speaker 1 (07:11):
Or before kids, before your crazy career, I feel
like it might be just a littlebit easier to change those
lifestyle habits, too, beforeyou find your spouse for the
rest of your life, because onceyou got those habits in place of
eating healthier, you're goingto find a spouse and stuff that
are is on the same page as youas well.
I'm struggling just right nowof my husband is he's very
(07:33):
supportive meat and potatoesfinish your plate, like so.
It's both of us getting out ofthe mentality where, as if I was
to have that lifestyle yearsago, I would have found someone
probably that had the same typeof lifestyle as well.
So, yeah, earlier, I think, is,but so much that would be so
much better.
Speaker 2 (07:53):
And you've talked about.
I think, sarah, you'vementioned also on something
which, when people have surgery,they sometimes don't
necessarily get the weight lossthat they expect, or over time,
they may regain weight or haveother things that crop up, like
reflux, which we all see in ourpractices too.
Tell me a little bit about howyou approach that situation,
where people are maybe beingtold you can do this on your own
(08:15):
or it's all about willpower orsomething else.
What is your approach to tofolks having had surgery and
maybe not being where they wantto be afterwards?
Speaker 3 (08:25):
Yeah.
So I think that's just.
That's one of the hardest thingI feel like as bariatric
surgeons we deal with.
So for one thing, before theyeven get their first surgery, I
think we all say this is a tool,this is not like some magic
pill.
You're not going to havesurgery in the next day, eat
what you want and just weightcomes off.
For the most part, everyonedoes lose weight and we quote 60
(08:46):
to 70 percent of their excessbody weight.
But I tell everyone, themajority of patients gain about
15 percent back.
It's that curve that comes backup.
But then again I do say it'sstill the most successful
because about two thirds ofpatients keep that weight off.
But we still have that onethird.
We have one third of sleeveslike I read a study that was 40
(09:08):
percent of sleeves that gained50 percent of their weight back
or more, which is quitesubstantial and even bypass.
about 20 percent of thosepatients gained a significant
amount of weight, not just smallamount of weight.
So then we get to this pointwhere we're seeing these
patients who've had it 10, 15,20 years ago.
And what do we do?
It's a lot more approach.
I tell them the process is alot more rigorous.
(09:29):
I do have every single one ofthem see our bariatrician, our
medical professionals, wherethey can help with medications.
I don't, I don't prescribe them, but they do and they're great
in our office I say look, yougot to start their program.
We got to see if there'smedications that can help with
this weight loss.
I always tell them most of thetime they've actually fall.
(09:50):
They haven't seen somebody inyears to follow up.
I say you got to go back to ourbariatric dieticians.
We start food logging, all thegood learning, the good habits.
And then the other part of myprocess is I do anoscopy.
I do go back in there andmeasure their sleeve or their
bypass to see with their size oftheir stomachs and whatnot.
That it's again.
(10:10):
It's a little bit more rigorous.
I usually takes a little bitlonger if they've gained weight
and we're either headed towardssurgery or just trying to get
the weight back off.
But most of the time I dorecommend especially to go see
our bariatricians, our medicalspecialists.
Speaker 1 (10:25):
And what is Surgeons?
Sorry Maria, but surgeons doSleeves and stuff stretch out,
quote-unquote.
Do they stretch out?
No, no.
Speaker 3 (10:39):
There's one study.
They did these contrasted.
They had people drink thecontrast that like shows
Stomachs are and they foundmaybe 10% of the stomach
stretches.
But it's not Verified reallyand I think from experience I've
gone back in there and scopedpatients and the sleep.
(10:59):
The stomach doesn't stretch Ifit's big.
It was always big to begin with, like they had made this.
Yeah, so if I go and scopesomeone who had a sleeve, maybe
15 years ago they used to use abigger measuring device, what we
usually they used to be like5660 French, which is just very
much wider and so the stomachswere just made bigger back then
(11:19):
because they, for whateverreason, that's what it was, and
so now we make the stomachs alot smaller.
So if I go in there and thesleeves really big or really
wide, it's not because it'sstretched.
It was most likely made wide tobegin with and same with a
bypass.
If I go in there and find a bigstomach pouch, it was because
it was always made big.
So the stretching at that istruly a myth.
(11:41):
We don't stretch the stomachsout and At the most it's 10% and
just not significant to thisand for weight gain.
Speaker 1 (11:48):
Yeah, so in that case , if you went in, someone had a
sleeve.
10 years ago you found out thesleeve was just big.
Can you re sleeve it?
Speaker 3 (11:59):
Yes, you can, yeah, you can do you.
I say, yes, I in fellowship wedefinitely did.
I personally haven't done it inmy practice yet because I
haven't come across it, but wehave.
And there again, there is thereyou can find any kind of study
for this.
But there is a study wepresented at a journal club
(12:19):
Resleaving a patient can causeweight loss, but it really has
to be the patient.
You go in there and you're like, wow, this sleeve was made very
large and we can actually getstomach tissue out.
Because you don't want to, yougo, we put our bougie in and you
go in there.
If you can't staple along it,then you can't get enough tissue
out.
But I have seen it done.
I did a handful of them andfellowship, and so it's not a
(12:42):
procedure that we, that's not.
We do it, but I'm veryselective.
Speaker 2 (12:46):
Patients, yes, yes you do mention patient selection
, which I think is a reallyinteresting concept, because I
think a lot of folks when theyhave these surgeries, they won.
The approach has been one anddone.
That's been the mantra for avery long time for this kind of
these procedures, mostly drivenby insurance, more than anything
else than that, than my data.
But you're bringing up a reallygood point, which is that
(13:06):
there's not a one-size-fits-allapproach, especially once people
have gone through surgeryalready, just because you've
regained weight or just becausesomething else has happened
Doesn't automatically buy youanother surgery, doesn't
automatically buy you a specifickind of surgery.
So how do you approach thosekinds of maybe Misconceptions,
or even encourage people to comein for a visit when they may
(13:26):
have some of those beliefs aheadof time?
Speaker 3 (13:29):
You said it's not one-size-fits-all.
I Always put encourage,encouragement that look, there's
surgical options.
So I don't want anybody and Itell people you don't have to
have surgery, because somepeople are like I've already had
one, I don't want to haveanother and that's fine, that's
totally okay.
But I will say, most of thepeople when they come see me
they're like those are anothersurgery option and I'm like we
(13:51):
always have options, but I dowant you to again, most of the
time I'd like them to trymedications first before going
to a second surgery.
But there's a wide array ofoptions.
Even for a gastric bypass.
We thought we do an endoscopicOutlet reduction, which is
pretty least invasive, orsometimes go back in there and
make their Bowels longer and iffor sleeve, there's plenty of
(14:15):
options converting them to aduodenal switch.
I think it's just not aone-size-fits-all and the key
thing is to not believeeverything you read online.
So I can't tell you how manypeople exactly.
Speaker 1 (14:26):
I see.
Speaker 3 (14:27):
Come in who've had a sleeve and they gain weight and
they're like, okay, I shouldhave had a bypass.
Or like, yeah, or okay, I'veread online if you gain the
weight back, you can convert itnow to a button.
You're like, okay, I, let'sstep back and have a
conversation, because that's notsimply true.
There's plenty that we see thatpeople don't lose more weight,
converting them to a bypass, sothat so, for weight gain alone,
(14:51):
conversion to a bypass orwhatever another surgery may not
be the answer.
Speaker 2 (14:55):
There's been some pretty interesting research
lately, especially that there'speople who just don't respond to
bariatric surgery, whether it'sa sleeve or a bypass or a seedy
or whatever it may be, andthat's really an unclear.
We don't really understand whyand we don't have any predictive
capability to find out whichpeople that affects.
What do you do when there's aperson who maybe has had a
(15:15):
surgery before, seems likethey're doing everything right,
maybe even a revision to anothersurgery, and they're still
having problems with weight orother comorbidities related to
weight?
Speaker 3 (15:26):
Yeah, that's a really hard case.
So I think the key thing is nowthey have the genetic studies
to do genetic studies and Ican't tell you that I know much
about that.
But I know when I talk to mybariatricians they're like, yeah
, we send them for their genes.
We actually, a main ClevelandClinic has a bunch of
practitioners who go in depthwith that.
But I think that's the nextstep is to send them for blood
(15:49):
work and whatnot and see wherethey can help.
Speaker 2 (15:52):
Yeah.
Speaker 1 (15:52):
I think the biggest takeaway there is if any of our
listeners are that patient,there's nothing wrong with you,
you're not doing necessarilyanything wrong.
The biggest reason for startingthis podcast is because if any
of those patients went onto aFacebook group and said I'm
struggling, they would all beattacked saying you're eating
(16:12):
too much, you're not movingenough, this, that and so.
That's where I really wantedthis education for those
patients that if you areregaining a little bit or if you
haven't lost anything, there'snothing wrong with you, that
it's not necessarily what you'redoing, it's just your body.
Speaker 3 (16:31):
Yeah, and everyone's weight loss trajectory is
different.
Like we have to compare it tobabies on that growth chart.
Speaker 1 (16:38):
Oh, they're like on that globe, yeah.
Speaker 3 (16:40):
And you're like okay, you could be above or below the
slope, that doesn't meananything's wrong with the baby.
Speaker 1 (16:46):
And I like that.
Speaker 3 (16:47):
But it does keep us accountable too.
So if you're not on the righttrajectory, again, that your
body could be different, but wealso.
That's time to pay review.
Let's see what are your dietaryhabits, what is the exercise?
What is your lifestyle Like?
Are you sleeping enough?
Stuff like that.
And again, it's just like thescale.
I think you guys said it keepsyou accountable, but it
shouldn't be a burden.
Speaker 2 (17:08):
Absolutely yeah, because there's so much.
There is so much that affectsweight and so many things that
we depends on it's not.
It's not one size fits all byany means of any approach.
So I'm curious, you hadmentioned some, a pretty
creative procedure which I don'tthink a lot of places are doing
, which is using a scope toactually do a revision
specifically on bypass patients.
(17:28):
Can you talk a little bit aboutwhat you're excited about in
kind of innovation in surgery inthis space and what kinds of
things you're working on oryou're excited about other
people working on in the futureto help with complex situations
for people?
Speaker 3 (17:43):
Yeah, so I was lucky enough to go to a fellowship
where my mentor really believedin minimally invasive or
incisionless surgery and he's agreat guy, so he, we tried a lot
of things endoscopically andone of the ones that has been
successful and actually quite afew gastroenterologists will
quite a few of them do this- but, essentially go without any
(18:05):
cuts on the belly at all.
They go.
We go through the mouth and doit with an endoscope and a
camera and we can suturestomachs a little bit tighter.
If you've had a gastric bypass,essentially we take your
opening and just make itpinpoint, like it'll be two
centimeters, we'll make it likehalf a millimeter or half a
centimeter, or even the sleeve.
We do the endoscopic sleeves.
(18:25):
I don't personally do them, butthere's plenty of places around
the country.
So again, you don't get cuts onyour abdomen.
I think the field is still.
There's got to be a lot morestudies on it.
I know there's plenty of.
There is research out there.
So I don't want to say thereisn't, but I think it's cool.
I don't think we should justput it down Like if I truly
believe no, there, becausethere's quite a few surgeons
(18:48):
around the country who are likeoh, endoscopic sleeve is fake or
doesn't work or whatever.
And I, you know I don't likethat mentality.
Just because it's innovative,it doesn't mean it hasn't, it
has to be perfected.
So yeah.
So I think it's cool, I thinkwe got to keep doing it and do
research on it.
And then the other key partabout it is eventually, when we
(19:08):
have good, successful data,which there's, some out there
try to get insurance companiesto approve it, which is always
the last and hardest step, thatis the hardest step?
Speaker 2 (19:16):
Yeah, Because the hard part is there's.
There is so much innovation inthis field, which is really
exciting from both the medicalstandpoint and the surgical
standpoint, and the spectrum ofcare that's developing out of
this, thankfully.
But what do you do about theinsurance lack?
Because even if you're in areally innovative program where
you did fellowship, for instance, right Cleveland Clinic, which
really is cutting edge in a lotof ways, how do you handle being
(19:39):
able to do much more but notnecessarily being allowed to buy
insurance or for reimbursementpurposes?
Speaker 3 (19:47):
It is such a hard field.
There is a little bitroundabouts of it.
We always all the codes werealways for open surgeries but we
use them for laparoscopic, sosome of those codes can
translate for endoscopic andinsurances will pay.
And I know they're working onthe procedure.
I was talking about outletreduction.
They're working on getting acode for that.
So part of it is just advocacytoo.
(20:08):
I know Maria works a lot onthis.
But try to go and be like weneed a CPT code, like you guys
have to get us a code and Ibelieve, for is it Sadi or a
single gastric bypass?
They've been fighting it andthey finally got one.
So we got to keep advocating.
That's one end and then theother end for the patients.
We're just, I'm honest withthem.
I say, hey, this is one ofthose procedures that may get
(20:31):
denied.
We'll give it a try to getapproval for you, but and we'll
fight it Like we'll do appealsand peer to peers and all this
others.
I am very upfront.
I'm say I do say paid to thepatients that it may not get
approved and then cash payoptions.
I know plenty of centers whohave cash pay options that are
reasonably priced.
Yeah, yeah.
Speaker 2 (20:52):
So a lot of options but still a lot of barriers to
potentially yeah.
Speaker 3 (20:56):
And this is another thing I want to plug in there is
that we have a lot of patientswho go overseas, or not even
overseas that other places- inthe country to get a gastric
sleeve or whatever surgery and Iunderstand a lot of them don't
have benefits.
They go seek it somewhere elsebecause they're like I want to
have it here but I can't pay forit.
So if you ever have that, seeka bariatric center and we can
(21:18):
refer you to somewhere in thecountry that has very reasonable
prices and but you don't haveto go somewhere else outside the
country.
So I do want to put a plug outthere for that, that there's
plenty of places in the UnitedStates.
Speaker 2 (21:31):
Yeah, I love that.
Speaker 3 (21:31):
I love that, Sarah.
Speaker 2 (21:32):
I think that's really important for people to know
that just because you go to onebariatric surgery program or one
center something doesn't meanthat you're going to be excluded
from care If you can't jointhem or if your insurance isn't
accepted, you're not just goingto be thrown to the wolves.
We all do this because wereally care about this field and
there are way more ways to makemoney than this industry for
(21:52):
doctors and for people in ourfield.
So there's a lot of compassion,I think, out there for people
who don't have insurancecoverage potentially or can't
afford certain approaches.
So I love that you said that.
I think that is so importantfor people to hear that they can
expect help and referrals evenif the place that they initially
start doesn't work for them.
Speaker 1 (22:14):
I want to ask you surgeons something, because this
came up with one of my friends.
A lot of people research thesleeve and just want the sleeve.
The sleeve is not necessarilyfor everybody, but sometimes
people are afraid of the bypass.
So explain why they might beafraid of it and why they
shouldn't be afraid of it.
Speaker 3 (22:33):
Maria, you want to take this one to start.
Speaker 2 (22:35):
Oh sure, but I will defer to you, sarah.
But basically, like I saidearlier, there's a lot of
misconception because this fieldis fairly new.
But a lot of surgeries used tobe done open and a lot of folks
had much more intense surgeries,much more intense recoveries
afterwards and also had highercomplication rates afterwards,
especially after bypasses anddo-it-all switches, which is
another form of rearrangingthings on the inside, and that
(22:58):
legacy unfortunately stillhaunts us pretty intensely.
Would you say, sarah, that'strue, go ahead.
No, I was going to say.
Speaker 3 (23:06):
So, as far as a gastric bypass goes, I want to
say it's been around 40 yearsnow.
It's the one surgery that'sheld true, We've had the band
have a rise and a fall, and eventhe sleeve.
It's successful and it was.
We think it's peaked and now alittle bit less.
So the truth is the gastricbypass has been around for such
a long time and they did do itopen and they used to have
(23:30):
complications and they werefiguring it out and that's so.
Now we've we have really almostperfected it.
It's such a good surgery andwe've come such a long way from
what it was 20, 30, 40 years ago.
Yeah, I agree with haunting usa little bit from what surgeons
and they were doing their besttoo.
So the complications, the ICUcare, all that stuff.
(23:52):
But that's how I reassure thepatients.
I tell them first that surgeryagain has held.
True, A bypass has shown weightloss for decades, so it is a
good surgery.
And then the complications.
Now that we do it with advancedtechnology is down to what a
sleeve is.
So I now leak rates when we'recomparing sleeves and bypasses.
(24:14):
They're almost the same.
So I tell them, as far asshort-term complications,
short-term recovery, it'sexactly the same.
Speaker 1 (24:22):
What about long-term, like malnutrition and?
Speaker 3 (24:25):
Yeah, so long-term it's again a pretty rare like
malnutrition vitamins.
Yes, definitely the sleeve ismore forgiving if you stop
taking your vitamins alltogether versus a gastric bypass
or a duodenal switch.
Speaker 1 (24:39):
She's mean mugging me , and I'm doing better, maria,
I'm doing better.
I love it.
Speaker 3 (24:44):
Yeah, it's true, it's as far as not so much
malnourishment because we do thebowel limbs again.
We come a long way.
It's very rare to getmalnourished with a gastric
bypass and even a duodenalswitch.
But as far as vitamindeficiencies, definitely Like
you can probably I don'trecommend it, but you can go
weeks and months and not takevitamins with a sleeve when
(25:07):
you're out and then you'reprobably not going to have too
much consequences versus if youdon't take your vitamins, for
gastric bypass or a duodenalswitch especially.
But the other thing I got tosay long-term is ulcers with a
gastric bypass and I deal withthis because I feel like half of
accurate smoke cigarettes.
Speaker 2 (25:26):
You're after their surgery.
Sometimes it's so bonkers to me, but people do.
Speaker 3 (25:30):
They're just.
I have so many smokers.
I've never dealt with this manysmokers in all my training and
my career so far.
So I will.
I always tell everybody it's.
If they're having problems witha gastric bypass, most of the
time it's because they're havingan ulcer.
And so unless you're doingsomething you're not supposed to
.
People do really well with agastric bypass.
Speaker 2 (25:50):
Noted Sounds good, yeah, yeah.
So that's a great questionthough, tammy, because it's a
lot of folks don't want to,don't even know how to ask the
question.
Necessarily, they just feelafraid, and hopefully this is
starting to break down some ofthat.
So, absolutely.
Speaker 3 (26:03):
That's great.
I'll tell you, my older nursesare the ones who've seen the
bypasses from 20 years ago.
They come to me and they'relike I don't want to bypass,
I've seen what it can do, right,and how do you explain it to
them?
That it's better.
That's the same way I say thattechnology has advanced.
If you remember, in the ICUthey had an open abdomen and
(26:26):
things like that.
I'm like they come around.
But I will say I've had quite afew older nurses who are like
I've seen what the bypass is.
Speaker 2 (26:32):
Yeah absolutely yeah, and they're definitely not
wrong about the past, buthopefully, with technology, we
are making things better and alot more knowledge about this.
Sarah, I'm really grateful thatyou spoke with us today.
I think you're really fightinga great fight in terms of
re-shifting the focus tobariatric surgery as preventive
medicine, and really I think Iwould love to be one of your
(26:53):
patients because you seem socompassionate and so thorough.
It's just been a real joy towatch your career so far and I'm
so grateful that people likeyou are contributing to this
field, because it couldn't bebetter as a result.
So thank you for taking time tobe with us today.
Speaker 3 (27:07):
Yeah, absolutely.
I just want to say this podcastis great.
I'm so glad you guys are doingthis.
I was listening to it and I waslike this is what I say to my
patients and what a great way tohave a lot of people hear it
and all these myths that youguys are debunking and it's
great.
I love it.
(27:28):
I'm referring my patients tothis podcast and you guys are
doing a lot of good work.
Speaker 1 (27:32):
I thank you so much for that.
That's why I do it.
Obviously, Maria and I stillhave full-time jobs.
We're just doing this.
In some days it is a lot, butstuff like that and patients
reaching out to me on Instagramand stuff and just saying this
is what I needed, is why we aredoing it 100%.
So thank you so much for sayingthat.
Thank you everybody forlistening.
(27:52):
Don't forget to go over toInstagram and follow us and send
us a message if you haveanything you want us to talk
about.
We also did open up a Facebookgroup, so Core Bariatrics
Community.
It'll just ask you questions ofwhere you heard about the group
and what you want out of it andwhatnot.
So, yeah, head over there andrequest to join.
(28:13):
Otherwise, thank you forlistening.
Thank you, Sarah, for beinghere and until next time, thank
you.
Thank you, guys.
Speaker 2 (28:21):
Bye.
Welcome to Core Bariatrics Podcast hosted by
Bariatric Surgeon Dr MariaIliakova and TMA LaCose,
bariatric Coordinator and apatient herself.
Our goal is building andelevating our community.
The Core Bariatric Podcast doesnot offer medical advice,
diagnosis or treatment.
On this podcast, we aim toshare stories, support and
(00:22):
insight into the world beyondthe clinic.
Let's get into it.
Speaker 2 (00:26):
Today we have with us a personal friend of mine who
did medical school at UMKC myStopping Grounds 2, residency at
Indiana University, fellowshipat the University of Texas
Health Science Center at Houstonand is now a Bariatric Surgeon
at Cleveland Clinic.
Let's please welcome with me DrSarah Monfred.
Speaker 1 (00:45):
Hello, sarah, hi, thanks for being here.
Speaker 3 (00:48):
Thank you for having me.
Speaker 1 (00:49):
All right.
So let's just jump right intoit why you got into Bariatric
Surgery and how you got thereand just dive right in.
Speaker 3 (00:58):
Yeah.
So from medical school I justhad an idea I wanted to do
surgery and general surgery wasmy path.
But then when I was inresidency it's interesting, we
all like love to operate andyou're like, how do I pick which
type of career?
So I am a little bit like, oh,I went with things that annoyed
me a little bit less than likeother surgeries, like
(01:20):
positioning.
I hated difficult positioningin the operating room and I was
like, oh, this is nice Arms out.
So a lot of it was just liketechnical, like this is the kind
of career I want to do, this isthe surgery.
But then the other half of itwas the patients I like to treat
obesity because I think itdeals with a million other
things like cancer and heartdisease and lung diseases.
(01:42):
During COVID we realized thatwas a cause of a lot of things.
So I was like, all right, thisis something preventative
medicine essentially.
And then just my own experiencewith weight up and down and I
was like, okay, I can relate tomy patients.
So those kind of were thereasons I headed towards
bariatrics.
Speaker 2 (02:01):
You mentioned preventative medicine and I
really am curious about that,because I think that one of the
things people don't necessarilyrealize is this is one of the
only surgeries that can serve toprevent the worsening of
disease or the development ofdisease.
Can you talk a little bit moreabout why that resonated for you
?
Speaker 3 (02:17):
Yeah, absolutely.
We talk about colonoscopies andhow they're like top reason of
decreasing colon cancer andeverything else smoking, all
this stuff that we're like, oh,we got to get ahead of it, get
your mammos.
And so, like I was like, why istreating obesity?
This is, in my opinion, thenumber one preventative medicine
.
It causes increased risk forbreast and colon cancer.
Obesity does so.
(02:38):
Treating that will help treatthe cancer and then treating
obesity is going to help youhave less heart attacks, less
stroke, all this stuff.
So to me I was like it's, in myopinion, the number one
preventative medicine.
And so, yeah, it was like,whether it's surgery or whatever
it might be, we have to treatthis disease and it is a chronic
disease, so it's not one ofthose where you can just be like
(03:00):
, oh it's one and done.
It's something people live withlifelong.
Speaker 2 (03:05):
In that preventative medicine vein.
Do you think that there'senough public awareness of that
or there's enough awarenessamongst other healthcare
providers that that can actuallyoccur through these surgeries?
Speaker 3 (03:16):
I think there is some awareness in most primary cares
and I think most physicianswhen they see someone who you
know, they tell them like oh,losing weight helps with
whatever they see a cardiologist.
Or like losing weight helps,but as far as still getting the
referrals and still sending themto bariatric surgery, I do
think we do struggle a littlebit because you guys have
mentioned this before we'restill telling people or you
(03:38):
don't have enough willpower.
So even amongst providers,we're still going.
Oh, if you just have a littlebit more willpower, you'll lose
weight, as opposed to actuallyreferring them to an obesity
medicine or bariatric center.
Speaker 2 (03:53):
Yeah, I'm always shocked by that.
It's oh, of course.
This person hasn't been tryingfor their entire life to do this
themselves and hasn't beenstruggling with it forever.
Speaker 3 (04:02):
And you would think, like I said, if you have your 40
and a female and you get yourmammogram, why not?
Hey, your BMI is above 35.
Why not see the specialist?
Whether you get anythingsurgery, medications, anything
why not?
Why is that not part of thepreventative things that should
be checkmarked?
Speaker 2 (04:21):
Okay, that's pretty interesting.
So talk a little bit more aboutwhat that would look like.
And let's say you could wave amagic wand and you can make that
happen.
What would that look like at 40for every woman?
Speaker 3 (04:30):
Yeah, I think that would be.
I don't want to put an age onit because that would be
difficult, but definitely, likewe tell everyone now 45, you've
hit 45, you're due for acolonoscopy or colagard, and
whoever the physician is or theprovider is goes.
This is a checkbox you got todo.
This is preventative.
Same thing, like I said, withmammogram.
So, yeah, I don't know what age, but in my opinion there should
(04:53):
be in the primary care setting.
So I would say, like your BMIis above 35.
I would like to refer you to aphysician.
You can discuss this and it's.
It doesn't.
Again, does not have to be like, oh, you have to have surgery
or even those discussionsbeforehand, but your BMI is 35.
Just have those discussions andit might mean like just an
office visit or a virtual visit,and I think that would be, and
(05:16):
most of these are also coveredby insurance, like we don't have
issues covering office visits.
Speaker 1 (05:21):
I think that would be such a good idea and I think if
people learned.
I think education aroundbariatric surgery and just
medications and stuff like thatis limited, because I think a
lot of this is newer than,obviously, colonoscopies and
stuff.
So I do think that education ishuge.
So if someone just went into,if my primary care doctor told
(05:44):
me to go to a bariatricsurgeon's office just to discuss
things sooner in life, I wouldhave been more educated and
maybe could have had surgeryearlier or been able to battle
things earlier.
So then it wasn't such I needto do this now.
It's a.
I want to do this now toprevent my high blood pressure.
I want to do this now toprevent complications with my
(06:05):
pregnancy.
Yeah, I like the way you lookat that for sure, and I think
that's where we should go forsure.
Speaker 2 (06:11):
Yeah, I think that's a pretty neat approach.
I agree, because when we talkabout preventative medicine,
we're really trying to fix theproblem before it happens.
So make sure people, like Tanysaid, have healthier pregnancies
before they get preeclampsia orgestational diabetes.
Make sure people never developdiabetes in the first place or
develop the high blood pressurewhich people are much, much
earlier now in the past coupleof decades.
(06:32):
So that's really interesting tome.
To just consider obesity carelike screenings, just like
colonoscopies or mammograms,that's a pretty, I think,
innovative approach.
Sarah, that's really cool.
Speaker 3 (06:43):
Yeah, I wish it.
Yeah, it's definitely a dreamof mine.
And I think the other thing is,like Maria will know, I hate
when I get a patient who'salready has so many
comorbidities and they're such ahigh risk and it's like we
could have done this 10 yearsago.
And so that's the other keything.
I think, especially with ouryounger patients and their 20s,
they're like oh, you're just inyour 20s, you can do it and I
(07:05):
think in your 20s and stuff likefor me, I think changing those
lifestyle habits definitely areeasy.
Speaker 1 (07:11):
Or before kids, before your crazy career, I feel
like it might be just a littlebit easier to change those
lifestyle habits, too, beforeyou find your spouse for the
rest of your life, because onceyou got those habits in place of
eating healthier, you're goingto find a spouse and stuff that
are is on the same page as youas well.
I'm struggling just right nowof my husband is he's very
(07:33):
supportive meat and potatoesfinish your plate, like so.
It's both of us getting out ofthe mentality where, as if I was
to have that lifestyle yearsago, I would have found someone
probably that had the same typeof lifestyle as well.
So, yeah, earlier, I think, is,but so much that would be so
much better.
Speaker 2 (07:53):
And you've talked about.
I think, sarah, you'vementioned also on something
which, when people have surgery,they sometimes don't
necessarily get the weight lossthat they expect, or over time,
they may regain weight or haveother things that crop up, like
reflux, which we all see in ourpractices too.
Tell me a little bit about howyou approach that situation,
where people are maybe beingtold you can do this on your own
(08:15):
or it's all about willpower orsomething else.
What is your approach to tofolks having had surgery and
maybe not being where they wantto be afterwards?
Speaker 3 (08:25):
Yeah.
So I think that's just.
That's one of the hardest thingI feel like as bariatric
surgeons we deal with.
So for one thing, before theyeven get their first surgery, I
think we all say this is a tool,this is not like some magic
pill.
You're not going to havesurgery in the next day, eat
what you want and just weightcomes off.
For the most part, everyonedoes lose weight and we quote 60
(08:46):
to 70 percent of their excessbody weight.
But I tell everyone, themajority of patients gain about
15 percent back.
It's that curve that comes backup.
But then again I do say it'sstill the most successful
because about two thirds ofpatients keep that weight off.
But we still have that onethird.
We have one third of sleeveslike I read a study that was 40
(09:08):
percent of sleeves that gained50 percent of their weight back
or more, which is quitesubstantial and even bypass.
about 20 percent of thosepatients gained a significant
amount of weight, not just smallamount of weight.
So then we get to this pointwhere we're seeing these
patients who've had it 10, 15,20 years ago.
And what do we do?
It's a lot more approach.
I tell them the process is alot more rigorous.
(09:29):
I do have every single one ofthem see our bariatrician, our
medical professionals, wherethey can help with medications.
I don't, I don't prescribe them, but they do and they're great
in our office I say look, yougot to start their program.
We got to see if there'smedications that can help with
this weight loss.
I always tell them most of thetime they've actually fall.
(09:50):
They haven't seen somebody inyears to follow up.
I say you got to go back to ourbariatric dieticians.
We start food logging, all thegood learning, the good habits.
And then the other part of myprocess is I do anoscopy.
I do go back in there andmeasure their sleeve or their
bypass to see with their size oftheir stomachs and whatnot.
That it's again.
(10:10):
It's a little bit more rigorous.
I usually takes a little bitlonger if they've gained weight
and we're either headed towardssurgery or just trying to get
the weight back off.
But most of the time I dorecommend especially to go see
our bariatricians, our medicalspecialists.
Speaker 1 (10:25):
And what is Surgeons?
Sorry Maria, but surgeons doSleeves and stuff stretch out,
quote-unquote.
Do they stretch out?
No, no.
Speaker 3 (10:39):
There's one study.
They did these contrasted.
They had people drink thecontrast that like shows
Stomachs are and they foundmaybe 10% of the stomach
stretches.
But it's not Verified reallyand I think from experience I've
gone back in there and scopedpatients and the sleep.
(10:59):
The stomach doesn't stretch Ifit's big.
It was always big to begin with, like they had made this.
Yeah, so if I go and scopesomeone who had a sleeve, maybe
15 years ago they used to use abigger measuring device, what we
usually they used to be like5660 French, which is just very
much wider and so the stomachswere just made bigger back then
(11:19):
because they, for whateverreason, that's what it was, and
so now we make the stomachs alot smaller.
So if I go in there and thesleeves really big or really
wide, it's not because it'sstretched.
It was most likely made wide tobegin with and same with a
bypass.
If I go in there and find a bigstomach pouch, it was because
it was always made big.
So the stretching at that istruly a myth.
(11:41):
We don't stretch the stomachsout and At the most it's 10% and
just not significant to thisand for weight gain.
Speaker 1 (11:48):
Yeah, so in that case , if you went in, someone had a
sleeve.
10 years ago you found out thesleeve was just big.
Can you re sleeve it?
Speaker 3 (11:59):
Yes, you can, yeah, you can do you.
I say, yes, I in fellowship wedefinitely did.
I personally haven't done it inmy practice yet because I
haven't come across it, but wehave.
And there again, there is thereyou can find any kind of study
for this.
But there is a study wepresented at a journal club
(12:19):
Resleaving a patient can causeweight loss, but it really has
to be the patient.
You go in there and you're like, wow, this sleeve was made very
large and we can actually getstomach tissue out.
Because you don't want to, yougo, we put our bougie in and you
go in there.
If you can't staple along it,then you can't get enough tissue
out.
But I have seen it done.
I did a handful of them andfellowship, and so it's not a
(12:42):
procedure that we, that's not.
We do it, but I'm veryselective.
Speaker 2 (12:46):
Patients, yes, yes you do mention patient selection
, which I think is a reallyinteresting concept, because I
think a lot of folks when theyhave these surgeries, they won.
The approach has been one anddone.
That's been the mantra for avery long time for this kind of
these procedures, mostly drivenby insurance, more than anything
else than that, than my data.
But you're bringing up a reallygood point, which is that
(13:06):
there's not a one-size-fits-allapproach, especially once people
have gone through surgeryalready, just because you've
regained weight or just becausesomething else has happened
Doesn't automatically buy youanother surgery, doesn't
automatically buy you a specifickind of surgery.
So how do you approach thosekinds of maybe Misconceptions,
or even encourage people to comein for a visit when they may
(13:26):
have some of those beliefs aheadof time?
Speaker 3 (13:29):
You said it's not one-size-fits-all.
I Always put encourage,encouragement that look, there's
surgical options.
So I don't want anybody and Itell people you don't have to
have surgery, because somepeople are like I've already had
one, I don't want to haveanother and that's fine, that's
totally okay.
But I will say, most of thepeople when they come see me
they're like those are anothersurgery option and I'm like we
(13:51):
always have options, but I dowant you to again, most of the
time I'd like them to trymedications first before going
to a second surgery.
But there's a wide array ofoptions.
Even for a gastric bypass.
We thought we do an endoscopicOutlet reduction, which is
pretty least invasive, orsometimes go back in there and
make their Bowels longer and iffor sleeve, there's plenty of
(14:15):
options converting them to aduodenal switch.
I think it's just not aone-size-fits-all and the key
thing is to not believeeverything you read online.
So I can't tell you how manypeople exactly.
Speaker 1 (14:26):
I see.
Speaker 3 (14:27):
Come in who've had a sleeve and they gain weight and
they're like, okay, I shouldhave had a bypass.
Or like, yeah, or okay, I'veread online if you gain the
weight back, you can convert itnow to a button.
You're like, okay, I, let'sstep back and have a
conversation, because that's notsimply true.
There's plenty that we see thatpeople don't lose more weight,
converting them to a bypass, sothat so, for weight gain alone,
(14:51):
conversion to a bypass orwhatever another surgery may not
be the answer.
Speaker 2 (14:55):
There's been some pretty interesting research
lately, especially that there'speople who just don't respond to
bariatric surgery, whether it'sa sleeve or a bypass or a seedy
or whatever it may be, andthat's really an unclear.
We don't really understand whyand we don't have any predictive
capability to find out whichpeople that affects.
What do you do when there's aperson who maybe has had a
(15:15):
surgery before, seems likethey're doing everything right,
maybe even a revision to anothersurgery, and they're still
having problems with weight orother comorbidities related to
weight?
Speaker 3 (15:26):
Yeah, that's a really hard case.
So I think the key thing is nowthey have the genetic studies
to do genetic studies and Ican't tell you that I know much
about that.
But I know when I talk to mybariatricians they're like, yeah
, we send them for their genes.
We actually, a main ClevelandClinic has a bunch of
practitioners who go in depthwith that.
But I think that's the nextstep is to send them for blood
(15:49):
work and whatnot and see wherethey can help.
Speaker 2 (15:52):
Yeah.
Speaker 1 (15:52):
I think the biggest takeaway there is if any of our
listeners are that patient,there's nothing wrong with you,
you're not doing necessarilyanything wrong.
The biggest reason for startingthis podcast is because if any
of those patients went onto aFacebook group and said I'm
struggling, they would all beattacked saying you're eating
(16:12):
too much, you're not movingenough, this, that and so.
That's where I really wantedthis education for those
patients that if you areregaining a little bit or if you
haven't lost anything, there'snothing wrong with you, that
it's not necessarily what you'redoing, it's just your body.
Speaker 3 (16:31):
Yeah, and everyone's weight loss trajectory is
different.
Like we have to compare it tobabies on that growth chart.
Speaker 1 (16:38):
Oh, they're like on that globe, yeah.
Speaker 3 (16:40):
And you're like okay, you could be above or below the
slope, that doesn't meananything's wrong with the baby.
Speaker 1 (16:46):
And I like that.
Speaker 3 (16:47):
But it does keep us accountable too.
So if you're not on the righttrajectory, again, that your
body could be different, but wealso.
That's time to pay review.
Let's see what are your dietaryhabits, what is the exercise?
What is your lifestyle Like?
Are you sleeping enough?
Stuff like that.
And again, it's just like thescale.
I think you guys said it keepsyou accountable, but it
shouldn't be a burden.
Speaker 2 (17:08):
Absolutely yeah, because there's so much.
There is so much that affectsweight and so many things that
we depends on it's not.
It's not one size fits all byany means of any approach.
So I'm curious, you hadmentioned some, a pretty
creative procedure which I don'tthink a lot of places are doing
, which is using a scope toactually do a revision
specifically on bypass patients.
(17:28):
Can you talk a little bit aboutwhat you're excited about in
kind of innovation in surgery inthis space and what kinds of
things you're working on oryou're excited about other
people working on in the futureto help with complex situations
for people?
Speaker 3 (17:43):
Yeah, so I was lucky enough to go to a fellowship
where my mentor really believedin minimally invasive or
incisionless surgery and he's agreat guy, so he, we tried a lot
of things endoscopically andone of the ones that has been
successful and actually quite afew gastroenterologists will
quite a few of them do this- but, essentially go without any
(18:05):
cuts on the belly at all.
They go.
We go through the mouth and doit with an endoscope and a
camera and we can suturestomachs a little bit tighter.
If you've had a gastric bypass,essentially we take your
opening and just make itpinpoint, like it'll be two
centimeters, we'll make it likehalf a millimeter or half a
centimeter, or even the sleeve.
We do the endoscopic sleeves.
(18:25):
I don't personally do them, butthere's plenty of places around
the country.
So again, you don't get cuts onyour abdomen.
I think the field is still.
There's got to be a lot morestudies on it.
I know there's plenty of.
There is research out there.
So I don't want to say thereisn't, but I think it's cool.
I don't think we should justput it down Like if I truly
believe no, there, becausethere's quite a few surgeons
(18:48):
around the country who are likeoh, endoscopic sleeve is fake or
doesn't work or whatever.
And I, you know I don't likethat mentality.
Just because it's innovative,it doesn't mean it hasn't, it
has to be perfected.
So yeah.
So I think it's cool, I thinkwe got to keep doing it and do
research on it.
And then the other key partabout it is eventually, when we
(19:08):
have good, successful data,which there's, some out there
try to get insurance companiesto approve it, which is always
the last and hardest step, thatis the hardest step?
Speaker 2 (19:16):
Yeah, Because the hard part is there's.
There is so much innovation inthis field, which is really
exciting from both the medicalstandpoint and the surgical
standpoint, and the spectrum ofcare that's developing out of
this, thankfully.
But what do you do about theinsurance lack?
Because even if you're in areally innovative program where
you did fellowship, for instance, right Cleveland Clinic, which
really is cutting edge in a lotof ways, how do you handle being
(19:39):
able to do much more but notnecessarily being allowed to buy
insurance or for reimbursementpurposes?
Speaker 3 (19:47):
It is such a hard field.
There is a little bitroundabouts of it.
We always all the codes werealways for open surgeries but we
use them for laparoscopic, sosome of those codes can
translate for endoscopic andinsurances will pay.
And I know they're working onthe procedure.
I was talking about outletreduction.
They're working on getting acode for that.
So part of it is just advocacytoo.
(20:08):
I know Maria works a lot onthis.
But try to go and be like weneed a CPT code, like you guys
have to get us a code and Ibelieve, for is it Sadi or a
single gastric bypass?
They've been fighting it andthey finally got one.
So we got to keep advocating.
That's one end and then theother end for the patients.
We're just, I'm honest withthem.
I say, hey, this is one ofthose procedures that may get
(20:31):
denied.
We'll give it a try to getapproval for you, but and we'll
fight it Like we'll do appealsand peer to peers and all this
others.
I am very upfront.
I'm say I do say paid to thepatients that it may not get
approved and then cash payoptions.
I know plenty of centers whohave cash pay options that are
reasonably priced.
Yeah, yeah.
Speaker 2 (20:52):
So a lot of options but still a lot of barriers to
potentially yeah.
Speaker 3 (20:56):
And this is another thing I want to plug in there is
that we have a lot of patientswho go overseas, or not even
overseas that other places- inthe country to get a gastric
sleeve or whatever surgery and Iunderstand a lot of them don't
have benefits.
They go seek it somewhere elsebecause they're like I want to
have it here but I can't pay forit.
So if you ever have that, seeka bariatric center and we can
(21:18):
refer you to somewhere in thecountry that has very reasonable
prices and but you don't haveto go somewhere else outside the
country.
So I do want to put a plug outthere for that, that there's
plenty of places in the UnitedStates.
Speaker 2 (21:31):
Yeah, I love that.
Speaker 3 (21:31):
I love that, Sarah.
Speaker 2 (21:32):
I think that's really important for people to know
that just because you go to onebariatric surgery program or one
center something doesn't meanthat you're going to be excluded
from care If you can't jointhem or if your insurance isn't
accepted, you're not just goingto be thrown to the wolves.
We all do this because wereally care about this field and
there are way more ways to makemoney than this industry for
(21:52):
doctors and for people in ourfield.
So there's a lot of compassion,I think, out there for people
who don't have insurancecoverage potentially or can't
afford certain approaches.
So I love that you said that.
I think that is so importantfor people to hear that they can
expect help and referrals evenif the place that they initially
start doesn't work for them.
Speaker 1 (22:14):
I want to ask you surgeons something, because this
came up with one of my friends.
A lot of people research thesleeve and just want the sleeve.
The sleeve is not necessarilyfor everybody, but sometimes
people are afraid of the bypass.
So explain why they might beafraid of it and why they
shouldn't be afraid of it.
Speaker 3 (22:33):
Maria, you want to take this one to start.
Speaker 2 (22:35):
Oh sure, but I will defer to you, sarah.
But basically, like I saidearlier, there's a lot of
misconception because this fieldis fairly new.
But a lot of surgeries used tobe done open and a lot of folks
had much more intense surgeries,much more intense recoveries
afterwards and also had highercomplication rates afterwards,
especially after bypasses anddo-it-all switches, which is
another form of rearrangingthings on the inside, and that
(22:58):
legacy unfortunately stillhaunts us pretty intensely.
Would you say, sarah, that'strue, go ahead.
No, I was going to say.
Speaker 3 (23:06):
So, as far as a gastric bypass goes, I want to
say it's been around 40 yearsnow.
It's the one surgery that'sheld true, We've had the band
have a rise and a fall, and eventhe sleeve.
It's successful and it was.
We think it's peaked and now alittle bit less.
So the truth is the gastricbypass has been around for such
a long time and they did do itopen and they used to have
(23:30):
complications and they werefiguring it out and that's so.
Now we've we have really almostperfected it.
It's such a good surgery andwe've come such a long way from
what it was 20, 30, 40 years ago.
Yeah, I agree with haunting usa little bit from what surgeons
and they were doing their besttoo.
So the complications, the ICUcare, all that stuff.
(23:52):
But that's how I reassure thepatients.
I tell them first that surgeryagain has held.
True, A bypass has shown weightloss for decades, so it is a
good surgery.
And then the complications.
Now that we do it with advancedtechnology is down to what a
sleeve is.
So I now leak rates when we'recomparing sleeves and bypasses.
(24:14):
They're almost the same.
So I tell them, as far asshort-term complications,
short-term recovery, it'sexactly the same.
Speaker 1 (24:22):
What about long-term, like malnutrition and?
Speaker 3 (24:25):
Yeah, so long-term it's again a pretty rare like
malnutrition vitamins.
Yes, definitely the sleeve ismore forgiving if you stop
taking your vitamins alltogether versus a gastric bypass
or a duodenal switch.
Speaker 1 (24:39):
She's mean mugging me , and I'm doing better, maria,
I'm doing better.
I love it.
Speaker 3 (24:44):
Yeah, it's true, it's as far as not so much
malnourishment because we do thebowel limbs again.
We come a long way.
It's very rare to getmalnourished with a gastric
bypass and even a duodenalswitch.
But as far as vitamindeficiencies, definitely Like
you can probably I don'trecommend it, but you can go
weeks and months and not takevitamins with a sleeve when
(25:07):
you're out and then you'reprobably not going to have too
much consequences versus if youdon't take your vitamins, for
gastric bypass or a duodenalswitch especially.
But the other thing I got tosay long-term is ulcers with a
gastric bypass and I deal withthis because I feel like half of
accurate smoke cigarettes.
Speaker 2 (25:26):
You're after their surgery.
Sometimes it's so bonkers to me, but people do.
Speaker 3 (25:30):
They're just.
I have so many smokers.
I've never dealt with this manysmokers in all my training and
my career so far.
So I will.
I always tell everybody it's.
If they're having problems witha gastric bypass, most of the
time it's because they're havingan ulcer.
And so unless you're doingsomething you're not supposed to
.
People do really well with agastric bypass.
Speaker 2 (25:50):
Noted Sounds good, yeah, yeah.
So that's a great questionthough, tammy, because it's a
lot of folks don't want to,don't even know how to ask the
question.
Necessarily, they just feelafraid, and hopefully this is
starting to break down some ofthat.
So, absolutely.
Speaker 3 (26:03):
That's great.
I'll tell you, my older nursesare the ones who've seen the
bypasses from 20 years ago.
They come to me and they'relike I don't want to bypass,
I've seen what it can do, right,and how do you explain it to
them?
That it's better.
That's the same way I say thattechnology has advanced.
If you remember, in the ICUthey had an open abdomen and
(26:26):
things like that.
I'm like they come around.
But I will say I've had quite afew older nurses who are like
I've seen what the bypass is.
Speaker 2 (26:32):
Yeah absolutely yeah, and they're definitely not
wrong about the past, buthopefully, with technology, we
are making things better and alot more knowledge about this.
Sarah, I'm really grateful thatyou spoke with us today.
I think you're really fightinga great fight in terms of
re-shifting the focus tobariatric surgery as preventive
medicine, and really I think Iwould love to be one of your
(26:53):
patients because you seem socompassionate and so thorough.
It's just been a real joy towatch your career so far and I'm
so grateful that people likeyou are contributing to this
field, because it couldn't bebetter as a result.
So thank you for taking time tobe with us today.
Speaker 3 (27:07):
Yeah, absolutely.
I just want to say this podcastis great.
I'm so glad you guys are doingthis.
I was listening to it and I waslike this is what I say to my
patients and what a great way tohave a lot of people hear it
and all these myths that youguys are debunking and it's
great.
I love it.
(27:28):
I'm referring my patients tothis podcast and you guys are
doing a lot of good work.
Speaker 1 (27:32):
I thank you so much for that.
That's why I do it.
Obviously, Maria and I stillhave full-time jobs.
We're just doing this.
In some days it is a lot, butstuff like that and patients
reaching out to me on Instagramand stuff and just saying this
is what I needed, is why we aredoing it 100%.
So thank you so much for sayingthat.
Thank you everybody forlistening.
(27:52):
Don't forget to go over toInstagram and follow us and send
us a message if you haveanything you want us to talk
about.
We also did open up a Facebookgroup, so Core Bariatrics
Community.
It'll just ask you questions ofwhere you heard about the group
and what you want out of it andwhatnot.
So, yeah, head over there andrequest to join.
(28:13):
Otherwise, thank you forlistening.
Thank you, Sarah, for beinghere and until next time, thank
you.
Thank you, guys.
Speaker 2 (28:21):
Bye.
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