You are about to choose the wrong surgery.

Right now, millions of patients are getting the sleeve because it is popular,because their friend had it, because someone told them it is the safest andleast invasive option. And nobody warned them about the reflux that can getworse, the diabetes that didn’t go away, and that the weight that comes backmore often.
If you choose the wrong operation, you don’t just lose results. You lose years.You end up back in a surgeon's office, heavier, sicker, and facing a revisionthat was completely avoidable. Stay for the next few minutes. This video couldbe the difference between the right surgery and a mistake you carry for therest of your life.
If you are watching this, you are probably considering weight-loss surgery, oryou have already been told you need it, and now you are trying to figure outwhich operation is right for you.
Here is the truth: there is no single best bariatric surgery. There is only thebest bariatric surgery for you.
Finding that answer requires a careful, individualized evaluation thatconsiders many different factors. It requires a surgeon who is comfortableperforming multiple procedures, not just one, so that the recommendation isdriven by what you need, not limited by what the surgeon can do.
And it requires shared decision-making. You and your surgeon review all theinformation, discuss the options honestly, the benefits, the risks, thetrade-offs, and make the decision together.
In this video, I am going to walk you through every factor I consider whenchoosing an operation for a patient. In the next video, I will show you howthese factors come together in real clinical scenarios.
But first, let me tell you about a patient I’ll call Maria.
Maria came to me after two years of researching bariatric surgery online. Shehad already decided she wanted the sleeve. Her sister had the sleeve. Hercoworker had the sleeve. Every video she watched said the sleeve was safe,simple, and effective. And she is not wrong. It is all of those things, for theright patient.
But Maria was not the right patient. She had a BMI of 52. She had been oninsulin for eleven years. And when I did her endoscopy, she had Grade Besophagitis and a four-centimeter hiatal hernia.
If I had just given Maria the sleeve because that is what she asked for, hereis what would have happened. Her reflux would have gotten worse, possiblydramatically. Her diabetes would have improved, but likely not resolved. Andwithin five to seven years, she would have been facing a revision surgery.
Instead, we had a real conversation. I showed her the data. I explained why agastric bypass with hiatal hernia repair would give her the best chance atreflux resolution, durable diabetes remission, and long-term weight loss. Sheasked hard questions. I gave honest answers. And together, we chose the bypass.
Eighteen months later, Maria is off insulin. Her reflux is gone. She has lostover 35 percent of her total body weight. And she did not need a revision.
That is what happens when the operation matches the patient, not the trend.
Let us get into it.

[RESUME EXISTING SCRIPT AT "THE OPERATIONS ON THE TABLE"]




All splicing instructions from the previous versionremain the same: cut everything from the original Cold Open through "Letus get into it," replace with this new material, and rejoin at "THEOPERATIONS ON THE TABLE."

How Your SurgeonChooses the Right Bariatric Surgery — Video 1 Script

HOW YOUR SURGEON CHOOSES THE RIGHT BARIATRIC SURGERY FOR YOU

Teleprompter-Ready Script (approximately 1,680 words / 13 minutes atteleprompter pace)

[COLD OPEN]

Imagine walking into a car dealership and the salesman hands you the keys to atruck before asking where you drive, how many kids you have, or whether youeven need a truck.
That is what it would look like if a surgeon recommended the same operation toevery patient.
But that is not how this works. Choosing the right bariatric surgery is one ofthe most important decisions you will ever make, and it should never beone-size-fits-all.
[INTRODUCTION]
Hello, and thank you for being here. If you are watching this, you are probablyconsidering weight-loss surgery, or you have already been told you need it, andnow you are trying to figure out which operation is right for you.
Here is the truth: there is no single best bariatric surgery. There is only thebest bariatric surgery for you.
Finding that answer requires a careful, individualized evaluation thatconsiders your weight, your medical conditions, your anatomy, your esophagealfunction, your prior surgeries, your mental health, your nutritional habits,and your goals. It requires a surgeon who is comfortable performing multipleprocedures, not just one, so that the recommendation is driven by what youneed,not limited by what the surgeon can do.
And it requires shared decision-making. You and your surgeon review all theinformation, discuss the options honestly, the benefits, the risks, thetrade-offs, and make the decision together. A JAMA review emphasized that allpatients with severe obesity should be engaged in a shared decision-makingconversation, and that the decision should be driven primarily by informedpatient preferences. Patients should be referred to surgeons comfortableperforming multiple procedures so they have the greatest opportunity to make aninformed choice.
In this video, I am going to walk you through every factor I consider whenchoosing an operation for a patient. In the next video, I will show you howthese factors come together in real clinical scenarios.
Let us get into it.
[THE OPERATIONS ON THE TABLE]
There are five primary metabolic and bariatric operations performed today, andthey exist on a spectrum from simpler and less metabolically powerful to morecomplex and more metabolically powerful.
Sleeve gastrectomy. The most commonly performed bariatric surgery in the world.We remove about 80 percent of the stomach, leaving a narrow tube. No intestinalrerouting. Expected weight loss is about 25 percent of total body weight at oneyear. Excellent safety profile. Mortality is less than 0.1 percent.
Roux-en-Y gastric bypass. The gold standard. We create a small stomach pouchand connect it directly to the jejunum, bypassing most of the stomach and theentire duodenum. Two intestinal connections. Expected weight loss is about 30to 35 percent of total body weight. The strongest long-term data of anybariatric procedure, over 30 years of follow-up.
One-anastomosis gastric bypass. A long, narrow stomach pouch connected to aloop of jejunum with one connection instead of two. Similar weight loss andmetabolic benefits to the Roux-en-Y, with a simpler technique and shorteroperative time. Now the third most commonly performed bariatric procedureworldwide.
SADI-S. A sleeve plus a single connection from the duodenum to the distalileum. Powerful weight loss and diabetes resolution. Growing long-term data outto 10 years showing sustained results.
Biliopancreatic diversion with duodenal switch, the Roux duodenal switch. Asleeve plus division of the duodenum plus two intestinal connections creatingthree limbs. The most powerful operation for weight loss and diabetesresolution. At 10 years, total weight loss of approximately 40 percent anddiabetes remission rates exceeding 90 percent. But it also carries the highestnutritional risk.
Now, how do we choose?
[FACTOR ONE: YOUR WEIGHT]
The first thing I look at is your BMI and where you fall on the spectrum ofobesity.
For a BMI of 35 to 45, any of the five procedures can work well. The choicedepends on other factors we will discuss.
For a BMI of 45 to 50, I start thinking more seriously about the gastricbypass, the one-anastomosis gastric bypass, or the SADI-S. The sleeve alone maynot produce enough weight loss in this range.
For a BMI above 50, the data strongly favor the duodenal switch or SADI-S. Arandomized controlled trial with 15-year follow-up showed that the duodenalswitch produced 37.5 percent total weight loss versus 22.8 percent for thegastric bypass in super-obese patients. A multicenter study of SADI-S versusbypass in patients with BMI 50 or above showed that SADI-S producedsignificantly higher and more sustained weight loss at every time point.
But BMI alone does not tell the whole story. I also consider body composition,age, and metabolic reserve. Older patients with more sarcopenia risk maybenefit from a less malabsorptive procedure with aggressive protein andresistance training emphasis. Younger patients may benefit from a more durableprocedure upfront rather than needing a revision in 10 to 15 years.
[FACTOR TWO: YOUR MEDICAL CONDITIONS]
Different operations have different strengths for different diseases.
Type 2 diabetes. All bariatric procedures improve diabetes, but the degree anddurability vary dramatically. The sleeve achieves remission in about 60 to 78percent. The gastric bypass achieves early remission in 75 to 92 percent, withlong-term complete remission in 30 to 54 percent at 10 or more years. Theone-anastomosis gastric bypass achieves remission in 71 to 94 percent. Theduodenal switch exceeds 90 percent. If you have severe, long-standing,insulin-dependent diabetes, I lean toward the bypass or duodenal switch becausethe intestinal rerouting produces a more powerful GLP-1 response and moredurable glycemic control. If your diabetes is mild and well-controlled on onemedication, the sleeve may be perfectly adequate.
Gastroesophageal reflux disease. This is a critical factor. The sleeve makesreflux worse. An 8-year prospective study found that 94.7 percent of sleevepatients had conclusive GERD by objective testing, compared to only 25 percentafter gastric bypass. A 10-year multicenter study found Barrett's esophagus, aprecancerous condition, in 16.8 percent of sleeve patients. Barrett's was foundalmost exclusively in the sleeve group.
My rule: if you have significant GERD, especially esophagitis on endoscopy ordaily acid-suppressing medication, I strongly recommend against the sleeve andin favor of the gastric bypass. If you have Barrett's esophagus, the sleeve iscontraindicated.
Sleep apnea, hypertension, and dyslipidemia all improve with every procedure,but the more powerful the weight loss, the higher the resolution rate. Forsevere sleep apnea with a high BMI, I lean toward a more powerful procedure.
[FACTOR THREE: YOUR ESOPHAGUS AND STOMACH
Before I choose an operation, I need to know what is happening inside youresophagus and stomach.
I perform or review an upper endoscopy on every patient. In a study of 885bariatric patients, 83 percent had at least one abnormal finding. Hiatalhernias in 43 percent. Gastritis in 32 percent. Barrett's in 2.7 percent. H.pylori in nearly 10 percent. These findings change the plan. A large hiatalhernia may favor the bypass. Barrett's rules out the sleeve. H. pylori must betreated first.
In select patients with dysphagia or atypical reflux, I obtain esophagealmanometry and pH testing. One study found esophageal motility pathology in 25percent of patients, rising to 41.5 percent in those with symptoms. Thisinformation directly influences whether I choose a sleeve, a bypass, orsomething else.
The preoperative workup is not a formality. It is how I discover theinformation that changes the recommendation.
[FACTOR FOUR: YOUR PRIOR SURGERIES AND ANATOMY]
If you have had prior abdominal surgery, especially upper abdominal surgery,adhesions may make certain procedures more difficult. A study of over 3,200bariatric patients found that those with major prior abdominal surgery hadlonger operative times, higher conversion-to-open rates, and morecomplications. The sleeve is generally the simplest procedure in a reoperativeabdomen. The duodenal switch is the most technically demanding.
If you have had a prior bariatric procedure, the revisional options dependentirely on what was done before. Failed sleeve with reflux goes to bypass.Failed sleeve with weight regain can go to bypass, SADI-S, or one-anastomosisbypass depending on the clinical picture.
Patients with inflammatory bowel disease, particularly Crohn's disease, may bebest served by the sleeve to avoid intestinal anastomoses.
[FACTOR FIVE: NUTRITIONAL COMPLIANCE AND LIFESTYLE]
Every bariatric procedure requires lifelong vitamin supplementation. But theintensity varies enormously.
After a sleeve, the nutritional risk is the lowest. After a bypass, the risk ismoderate, particularly for iron, B12, calcium, and vitamin D. After a duodenalswitch or SADI-S, the requirements are the most intensive. A 10-yearcomparative study found nutritional complications in 53.5 percent oftraditional duodenal switch patients versus 15.6 percent after SADI-S.
If a patient struggles to take medications consistently, has poor follow-uphistory, or has limited access to high-quality protein, I am very cautiousabout recommending a duodenal switch. The more powerful the operation, the morepowerful the commitment it requires.
[FACTOR SIX: MENTAL HEALTH AND BEHAVIORAL READINESS]
Every patient undergoes a psychological evaluation. We screen for depression,anxiety, binge eating disorder, emotional eating, and substance use. Theseconditions do not disqualify you, but they must be identified and addressedbecause they directly affect outcomes.
Alcohol is absorbed more rapidly after gastric bypass and duodenal switch. If apatient has a history of alcohol misuse, I discuss this openly and factor itinto the procedure choice.
[FACTOR SEVEN: YOUR GOALS AND PREFERENCES]
After evaluating all the medical factors, there is one more piece that matters:what do you want?
Some patients want maximum weight loss and will accept more complexity. Somewant simplicity and fewer long-term requirements. Some prioritize diabetescontrol. Some prioritize quality of life.

All of these preferences are valid. This is what shared decision-making means.I bring the medical expertise. You bring the knowledge of your own life.Together, we find the right answer.
No surgeon should ever tell you this is the only option. And no patient shouldever choose a procedure based solely on what a friend had or what they saw onsocial media.
[CLOSING]
Those are the seven factors I evaluate for every patient: weight, medicalconditions, esophageal and stomach anatomy, prior surgeries, nutritionalreadiness, mental health, and personal goals.
In the next video, I am going to take these seven factors and show you exactlyhow they come together in real clinical scenarios, eight different patients,eight different decisions, and the reasoning behind each one. I will also walkyou through the complete preoperative evaluation so you know exactly what toexpect before surgery.
Thank you for watching.
Real science. Real surgery. Real results.

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