Hello, I'm Dr. Nester Dela Cruz Munoz, a bariatric surgeon in Miami, and this is part of our pre-operative education process uh video series for patients considering undergoing beriatric surgery. So, welcome aboard. Uh if you have any uh doubts or you've missed, we have two ser uh two videos in the series before this uh that you're more than welcome to watch on the channel. All right, so let's get started. Um where we finished last time, we were talking about outcomes of different uh treatment options. Um but this time we're going to jump on into who qualifies for surgery. And uh this is patients with a BMI above 30 with comorbid conditions or patients uh with a BMI above 35 or higher. Uh it's already been shown that the morbidity mortality risk of not doing anything is higher than the risk of undergoing beriatric surgery. So before surgery what do we do? We see them in the office. We do a full history and a physical exam. All patients get a psychological evaluation. All patients see the nutritionist at least once. many of them multiple times um to get everything through about so they can understand the pathway before and afterwards as far as nutrition goes. Um everyone gets some x-rays uh an endoscopy, some blood work and other evaluations as needed. Some will see the cardiologist, some will get sleep studies, some will get ultrasounds. It just depends. And then everybody will put on a very lowc calorie pre-operative diet. And the reason is to shrink the liver, get some of the fat and some of the glycogen out of it to make it smaller, makes it safer to do the operations. Um, and postoperatively, same thing. We want to see you guys forever. We don't want patients to disappear. This is a lifelong follow-up. Um, and as and as well as us, we want you to be following up with your primary care physicians, uh, with our nutritionists who we're going to continue to, uh, work with, an exercise program, and in a support group. So, the key is we want to see you for the rest of your life. Okay? There are no former patients here. And then the different surgical procedures. It may surprise some people, but we offer six different uh, surgical procedures. a sleeve gasterectomy, ruin y gastric bypass, a one anastmosis gastric bypass, a magnetic douadino iliotomy with sleeve, a single anastmosis douadino uh switch and a ruin y douadino switch. Bunch of different options pretty confusing uh but let me help you break it down a little bit over the next few slides and we'll talk about that again if I see you in person. So how does beriatric surgery actually work? The answer that I normally get from almost everyone, including some buriatric surgeons, is by restriction and malabsorption. By making the stomach smaller, we just don't let the patients eat as much as they want to be able to eat because they can't. They fill up quickly. And that's really not how it works. Um, the patients are happy afterwards. And it's because the way these surgeries work is hormonal and other methods, but they decrease the desire to eat so much, not take away the ability. Um so uh gut hor gut hormone alterations increases in GLP1 and PY. Most of you guys have heard of GLP1 by now. Uh but the gastric bypass increases that hormone um naturally uh afterwards and actually in much higher levels than people get even when they're taking the medicines. Um this helps with fullness uh after meals and with with blood sugar as well. It decreases ghrein. Most of the surgeries help decrease ghrelin which decrease the hunger um and that helps patients so that they don't feel as much stress over all of that and actually some of the dopamine uh uh reward uh center uh changes are also interesting because the reward center is not quite as strong and so there's less food noise uh throughout the day. There's bile acid signaling uh which happens in some of the different operations and the increased levels increase insulin sensitivity and glucose homeostasis. So it helps directly with diabetes and with the metabolic syndrome that's happening in a lot of patients and uh this starts decreasing the inflammation. There's uh gut microbiome remodeling. So we all have a bunch of bacteria in our colon and uh what it's been shown is that patients that are suffering from obesity compared to patients that are thin have less variety of that of that intestinal flora. Um and so it puts them at higher risk for the obesity. And it's been shown that if you do fecal transplants of patients who have gastric bypass and give it to patients who have undergone uh who are suffering from obesity, many of them will get some of the metabolic changes that we see in in bypass patients. Um there is atapost tissue remodeling. Uh there's a big loss of the visceral fat or the fat around the organs. This is the dangerous fat that causes a lot of the inflammation. Um the fat cells themselves also change size and shape and uh it helps and because there's not as much insulin resistance being developed in the fat anymore. So that that's another effect. And there's altered energy expenditure. There's some some studies now showing that the brown fat that we have in in portions of our back may get stimulated. And this brown fat is actually good fat in that it helps burn extra energy and it normally keeps us warm but it it can help it can be turned on to to burn extra calories. So the first operation I'm going to talk about is the most commonly performed operation in the world right now. Uh it's a sleeve gasterectomy. Um it was first done in about the year 2000. Uh and what it essentially is a resection of the outside portion of the stomach leaving the stomach like a small tube. Um and it's called the gastric sleeve. So we resect about 75 to 80% of the stomach leaving it like a small tube and the food goes down the intestines the normal way. So the pros and the cons of this expected weight loss are about is about 25 to 30% total body weight loss uh making it very highly effective. There's no intestinal rerouting so the food goes down its normal way. There's lower risk of nutritional deficiencies uh because again the food is going its normal way. So there's a good chance for the intestine to absorb the nutrients it needs and it's a shorter operative time than some of the other operations uh and simpler to do uh so it's a little lower risk. The cons are that it's irreversible. Of course, we have to take out that piece of stomach and and throw it away. You can't put it back in later. Um, but you're only taking out a portion of the stomach, not the entire stomach. Um, there is a possible risk of development or worsening gastroosophageal reflux disease, which is heartburn. Maybe in about 25% of the patients. Uh, some of them will need to be treated on medicines and occasionally we will have to reoperate on somebody for severe enough reflux. the risk of weight regain is a little bit higher than the ones for than the other operations in here the chances of having regained a significant amount of weight is about 30 to 35%. Okay, number sounds very high but when you consider about a 97 to 98% chance of regaining weight with diets it is still a significant improvement and um it doesn't provide some of the malabsorption of some of the distal bypasses that we have which may limit weight loss in some patients. The next operation we're going to talk about is the second most common one in the world. It's the Ruin Y gastric bypass. This one was first uh invented in 1967. So, it's been around for a long time. Uh and here what we're essentially doing is creating a small patch of stomach and separating out the rest of the stomach. Although we don't resect this, it stays behind. Then we cut the small intestine down below. Bring up the piece that was more distal and attach it to the stomach above. Um and then farther down attach the two pieces of intestine together. So what that allows is for the food to come down this way in here and here it mixes with the gastric juices, the pancreatic juices and the bile that are flown down this this other limb and and mixed further down. So digestion begins from here on down. Okay. So this is one's done with two bowel unions and it's called the ruin y gastric bypass. The bypass pros and cons expected weight loss about 30 to 35% total body weight loss has been provenly long-term effective with decades of of data. This one's been studied for a long period of time. Um and uh we even published some of our data at at 14 and a half years. Patients still had an an average of about 31 a.5% total body weight loss. So it really has been shown to work. Uh the chances of regaining weight for this operation are listed at about 20 to 25%. So significantly lower than the sleeve. It has better remission rates for type two diabetes and improvement of other obesity related comorbid conditions. So the sicker patients are the more I start pushing towards uh these types of bypass types operations that are more likely to help improve these things. Uh it improves quality of life and reduces cardiovascular risk uh significantly. It's been shown to decrease uh heart attack risk by about 40% and stroke risk by about the same. um huge changes in patients, big increases in in quality of life and in uh and in overall health. Complications or cons, I'm sorry. Uh it's uh surgical complexity is higher compared to a sleeve. So, it takes a little bit longer to do and and the team has to be more experienced. I've been doing a gastric bypass since the year 2000. Have done about 5,000 and something of these, a lot of these. Um and so so we've gotten it down to where where normally these operations take me about 45 to 50 minutes to to perform. Um the risk of dumping syndrome something that's talked about a lot but it doesn't happen that often because our patients are well educated beforehand but it's basically has to do with eating high sugar foods and feeling sick if you do so. And then the potential for vitamin and mineral deficiencies. Um again we track all of our patients vitamin levels for life and uh we make we do supplementation for all of them because we found that many patients even have have vitamin deficiencies before before surgery. The next operation is the one in aimosis gastric bypass. Many Americans haven't heard about this bypass. It's done a lot more in Europe uh and it's coming more to the United States. And it's kind of like a gastric bypass in that you make a small gastric pouch, but this gastric pouch is longer than the than the gastric bypass and the ruin y gastric bypass. And instead of doing two anastmoses and cutting the small intestine, all you're doing is bringing a loop up and doing one inosis here. So the food comes into the stomach pouch and goes down distally. And what happens is all those digestive juices are coming back up this way and they mix with the food right here at the anastmosis. Okay? So it simplifies the procedure um and it's a longer bypass than a ru and y gastric bypass. So because it's longer the uh bypass than a ru and y gastric bypass. It has a little bit more expected total body weight loss. Um it says about 30 to 35% but it's probably a couple of points higher than a than a bypass on average and the surgical techniques is simpler. It has fewer complications. um there is better improvement in the comorbid conditions than a gastric bypass because again we're we're doing a longer bypass. So there's more stimulation of the distal small intestine which helps increase those hormonal responses even more and the less complex anatomy compared to gastric bypass can make follow-up a little bit easier as well. So the cons against this surgery are there's a risk of bile reflux. So while patients don't normally get acid reflux, they can get some bile reflux since those juices are coming back around. um and irritate the the stomach and the esophagus afterwards. Um there's there's more potential for vitamin mineral deficiencies after this because as I said, it's a longer bypass. It's it's almost moving into the malabsorptive range. Um so we really have to add some extra vitamins and follow a few extra vitamins every year to make sure that those levels are okay. And then there's less long-term data available than the rue gastric bypass just because it hasn't been done as often in the US and around the world. It was started relatively recently as well. Um, but it is a great procedure and I do this more often in patients who have more severe type 2 diabetes and the BMI range in the 40 to 50 type of range. Um, so have there have been excellent outcomes for for this. Um, then the ruin y douadino switch. This is the original douadino switch type operation. We're going to talk about three different ones. Um, this is the original one. Just like a gastric bypass, it's a ruin Y, meaning there two in aosis. You see one here and one down here. So, you're doing a long bypass just like a gastric bypass, but much longer than a gastric bypass. So, there's much more malabsorption here. Um, and the top part because you have because you have such malabsorption, you have to be able to eat some more. So, you have a sleeve instead of a small gastric pouch. um these patients lose it can be about 42% total body weight loss and they have excellent remission rates um of type 2 diabetes. In some studies it's at at 95% type 2 diabetes remission rates. So the resolution of comorbid conditions is excellent with this u but it is a higher complex uh operation. the risk of nutri nutrient deficiencies is higher and uh we really need to stay close eye and I've seen patients develop nutrient deficiencies as well as malnutrition with this operation. So we need to really stay on top of these patients and for for in my opinion we use this in BMIs well above 50 with severe metabolic disease. So patients that are already sicker and have much much higher weights need to lose a lot more weight in order to get healthier. This may be the type of operation that we that we talk about. So a modification of that operation that's a simpler one. We talked about the one anastmosis gastric bypass. Now this is the one andastmosis douadino switch but it's called the single anastmosis douadino switch. And essentially you're creating a gastric sleeve cutting the small intestine at the end of the sleeve and bringing up a loop of intestine. So you only have one anastmosis here and the food comes down and goes down distally. So there's a long bypass, much longer than a gastric bypass, not as long a bypass as the ruin wide douadino switch. So the weight loss is a little less. It's about uh 35 to 38% rather than 42%. The surgery time is less than than the regular uh ruin Y and and less complications. Um but you still have to do the lifelong monitoring of the of the and supplementation in order to make sure that everything uh stays good with this patient. This one, this is one of the fastest growing operations that we're seeing because some patients if they have a sleeve gasterectomy and they are regaining weight uh are great candidates for a conversion to a uh sadi operation. Um and they can do very well postoperatively with this. And then this is a new operation that that is out um that is still it's not a standard operation and we use it as a staged operation because we do not have long-term data yet. But it's a novel procedure and what it does is it uses magnets to create the anastmosis instead of staples or or suturing. And and the difference with this operation is that you use magnets to form the anastmosis here, but instead of cutting the small intestine, you let it go, you let it stay intact and so the food can go down its normal way as well as the bypassed way. So there's two different ways the the food stream goes and that's called a birectional anastmosis. And with doing this, we are theoretically decreasing the risk of vitamin deficiencies because some of the food is going down its normal way. So, it has a better chance of being absorbed normally. Um, but yet we're still stimulating the the distal small intestine with food that hasn't been well digested. So, it gives a much better kick for the hormonal changes and the gut changes that we need to help improve the comorbid conditions and cause the weight loss. Okay. So, I think this is one. Um, I'm offering this often in patients whose BMIs are above 50, uh, maybe not quite as sick, uh, and especially young patients because it's easily reversible, too. You can come back in the future and cut the sasteosis and it's essentially back to a regular sleeve anatomy. Um, so I like this in my young patients whose BMIs are well above 50. Um, because it doesn't add much risk that an that magnetic and is very low risk. Now we're comparing the different procedures and and I put this tons of numbers but so you have the data. Uh you can pause the screen so you can take a close look at it. Um but this is the six different operations and I'm comparing the six and as you'll see the basic thing to see is that for most of this the for the top parts that are in black most of the complications are under 1%. Okay. Um the biggest complication that we see most often is bleeding and it's about one and a half to 2% in the sleeve and about 1 to two same thing in a bypass and you see it's it's about the same for all the different operations but that's our highest one the leak rates in the literature about half a percent 4% about half a percent even 1 to 1 and a half% uh luckily I've been under 2% now for years uh with the leak rates which is about 2 in a thousand so it's very small uh risk of that um and and even the other complications are are very low. The reoperation rates are low. They're 1 to 3%, 2 to 4%, 2 to 5%. Um the highest ones are the douadino switch is 6 to 10% and 5 to 8%. Um I can tell you these are national numbers. These are not my numbers. Um my numbers are are a bit lower than that. And same thing the readmission rates anywhere from 3 to 15% after surgery. Uh we are at about a 1 and a half to 2% readmission rate right now. Okay. And the mortality rates if you look at this 05 to 0.1% 0.1 to 0 2% uh.3 to 0.5% even for the for the douadino switch 0.5% means one in 200 patients will pass away getting it done uh.1 is one in a thousand um and right now our numbers are like 0001% uh for mortality. So, it's very unlikely to happen. Uh, but is possible. But the funny part is everybody talks about how risky beriatric surgery is. So, I wanted to show you something. Um, on this slide here, we're going to compare it to different types of operations that patients get. And if you look for gallbladder surgery right here, laparoscopically, colon surgery, and a joint replacement, everything you see red is higher than higher risk than a gastric bypass. Um, not even than a sleeve, but than a gastric bypass. So if we look at um the complication rates the the gallbladder complication rates are about the same as a gastric bypass for most of the things but the mortality rate is just as high.1 to 2%. So it's not any riskier than taking out your gallbladder. Uh and it's a lot less risky than taking out your colon or getting a joint replaced. So the fear of beriatric surgery has been brought into people because of the obesity stigma and the desire for patients to not get surgery done. Um but it's unfounded and the benefits are tremendous. We talked in the last video that the mortality rates go down anywhere from 30 to 90% after beriatric surgery. That means the risk of dying goes down 30 to 90%. Okay. uh there was a great study out of Canada that showed also the risks of getting admitted to the hospital, the number of days patients spent in the hospital and the number of of medicines they were taking were all down in the patients who underwent buriatric surgery compared to patients that did not undergo beriatric surgery. So it's a huge deal. Um, I know it's a scary thought, but just like any other disease process that's out there, there's a very effective treatment um that actually saves more lives than most of the other treatments that we even offer. What do we do afterwards? We want to see you guys forever. And I've said this multiple times. Uh, and this is our followup. You know, the number of times we see you in the first year, second year, and every year thereafter. Um, so it's something that we do want to see you in follow up and see you for a long, long time. And then your decision again. so that you can freeze the screen. Let me step out of the way um and look at the different procedures. Uh and what you'll basically notice is the sleeve least risky, least invasive, uh less effective for weight loss compared to the other surgical procedures. Um but and uh less uh comorbid uh resolution compared to the other procedures, but all still very effective in terms of every other option for obesity. Um so I put them from worst to better to best. Uh, and you'll see that of course the ruin Y douadal switch is the best for some of these categories, but it may not be the best for you. Um, it's just a you have to weigh all the pros and cons. All right. Um, so next steps, transform your health. Please don't ignore the obesity. It's a huge deal. Um, you know, you should be working on losing weight. Uh, if you have any questions or want to find out more, you're more than welcome to comment on this video. Call the office there. Um, this is also the um QR code uh for the office information as well. Uh, and the office can talk to you about what your insurance company requires and how to get you through the process. Okay. Ask about financing options if you don't have insurance that covers it. Uh, we do have options for things that can cover it and and I think it's important um to get to look into the different plans. You may find that it makes a huge difference in your life. So, um, at the very least, get started working with your doctor, trying to lose weight, get on a diet, get it documented, because if in the future you decide to get surgery and you want to go through your insurance, most of the times they require a documented physicianled uh, diet plan to get you through. So, see them every month, get it all documented on the diet, the exercise, and the weight that you that you're at. And, uh, that helps the whole process get sped way up when you finally come see us. All right. Thank you very much. Um, and as I said, if you have any questions, please be sure to comment uh below or call us at the office at any time. Um, again, I'm Dr. Nester Dela Cruz Munoz. Real science, real surgery, real results.

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