Try as they might, some people will just never be able to lose enough weight through diet and exercise to be considered healthy. We all know one or more of these folks – the “fat friend” who needed to buy a seatbelt extender to ride on an airplane or who could never fit onto the roller coaster.
In addition to the social aspects of morbid obesity, defined as a body mass index over 35, the medical consequences include diabetes, heart disease, sleep apnea, and high blood pressure.
Weight loss surgery offers a way out. Over the years, bariatric surgery has become more and more refined, said Dr. Jonathan S. Aranow, a bariatric surgeon at Middlesex Health’s Center for Medical and Surgical Weight Loss. During an interview on Zoom while drawing a diagram of the digestive system, Aranow explained a relatively new procedure called the SADI-s, which offers patients lasting weight loss, and which can be more effective than, say, the gastric sleeve surgery alone. Here are some excerpts from the conversation.
Q. What is the SADI-s?
A. SADI-s stands for single anastomosis duodeno-ileostomy with sleeve gastrectomy. It’s a combination of a gastric sleeve surgery and a gastric bypass. It’s a minimally invasive procedure done laparoscopically. We remove 80 percent of the stomach, making a banana-shaped stomach. We get rid of the part of the stomach that produces the hormones that make you hungry.
We divide the duodenum (the first part of the small intestine, right next to the stomach) and connect it to the small intestine. We bypass (reroute) 80 percent of the small intestine.
You can have this surgery all at once, or the second part, the duodenal switch, as a “rescue operation” after having a gastric sleeve procedure. When patients have the surgery, they get a diabetes cure rate of 85 percent. And it offers a 90 percent success rate for weight loss to get the BMI below 35 (see sidebar). It’s far more successful than the gastric sleeve alone.
The biggest complication is GERD (gastroesophageal reflux disease, a digestive disease that occurs when the stomach acid irritates the food pipe lining), and some patients get diarrhea when they overeat carbohydrates.Other complications include gallstones.
Patients do well when they eat small, protein-based meals. Because of the intestinal bypass, patients have to take vitamins and nutritional supplements. At Middlesex, we have a comprehensive program that combines patient education, surgery and follow-up so that patients get the support they need to do well going forward. Long term follow up is key for lifelong success.
Q. Why is it that some patients who have had a gastric sleeve procedure alone don’t get the results they are looking for?
A. Perhaps the patient had too high a starting weight (e.g., BMI >50) or they had fairly resistant diabetes (i.e. insulin dependent). It depends on what the patient was looking for. Was it a weight loss result or a diabetes cure? For some, it was just the odds – as with all diseases, some are more malignant and resistant to treatment than others, and the sleeve may not have been an aggressive enough therapy.
Q. Why does the “rescue procedure” of the duodenal switch work?
A. It gives additional hormonal modification that results in improved blood sugar levels, improved appetite suppression, and reduced caloric absorption. As opposed to the sleeve and bypass where rapid weight loss maxes out at one year, the switch continues to promote additional gradual weight loss for an additional one to two years.
Q. Who is a candidate for the surgery?
A. So when I say morbid obesity, it’s the weight range where people’s health is compromised by weight. With a BMI of 35 or 40, people are about 100 pounds overweight. If a person has a BMI of 40, they are a candidate. At that weight, we do see an increased risk of cancer, high blood pressure, and other illnesses. The unfortunate fact is, once you get to that weight range, you can’t lose weight by diet and exercise. Some 95 percent of people are heavier five years later, if you look at studies. Weight loss is rarely maintained. If the BMI is 35, but they also have an illness like high blood pressure or type 2 diabetes, they are also a candidate. Our oldest patient is 78 years old. We operate on people age 17 and up. After surgery, people will live a healthier life and have a better quality of life. Surgery always wins. It improves your life expectancy about 30 percent.
Q. What is the recovery time?
A. There’s an overnight stay in hospital then most people get back to work in several days. If they work in manual labor, it’s a week or two until they get back to work. It’s one of safest procedures. The stomach is causing a disease that is causing diabetes. Why not have that stomach removed?
Q. What is life like after surgery?
A. For most people, it’s a whole lot better. It feels revolutionary. They can cross their legs, run around with the kids and not be embarrassed. There’s so much bias against overweight people. The surgery liberates them, and that is a huge change. They will lose the majority of their weight in one year. With the SADI-s, their weight continues to drift down for next two years. They’ll never have that rebound. It’s not a matter of will power. They’re just not hungry. It’s nice to be able to eat and not worry. Most people eat an 800 to 1200 calorie a day diet. Patients will need to take supplements and vitamins to ensure they get proper nutrition. Life is pretty normal and better than normal. They’ll see a reduction in diabetes, high blood pressure, sleep apnea, and arthritis. Their overall quality of life is better. It’s all good.
Q. Tell us about some patients who have had the procedure.
A. One (female) SADI-s patient started with a BMI of 45, and she was on 300 units of insulin a day. Three weeks out from surgery, she did not take a single dose of any medication for diabetes. From day one, she had a normal blood sugar. There is no other nonsurgical cure for diabetes. Diabetes causes renal failure and blindness. If I were diabetic and overweight, I would be seeing a bariatric surgeon. We had another patient, a 45-year-old man who wanted a kidney transplant because of diabetic kidney disease. Now, he’s no longer diabetic and was able to get a transplant. He’s living a much more normal life. Eight years ago, he couldn’t walk, he had blood clots, a pacemaker, was diabetic, and had arthritis. We see a lot of people in their early 20s with a BMI of 40, and they’re tired of being obese. They want to have their lives back and prevent all those other illnesses that come along with morbid obesity. With surgery, they lose 100 pounds in a year.
Q. Does insurance cover the procedure?
A. Connecticut does not have mandatory insurance for weight loss surgery. (As of May, 2020, a bill to require health insurance companies to cover weight loss surgery was pending in the Connecticut Legislature.) I’ve testified numerous times before the state legislature about the topic. Only about 50 percent of health insurances cover it. So if you own a small business, your insurance may not cover the surgery. It’s a very unfair, biased policy, particularly against African-American and Latinx people.
Q. How do patients get started?
A. Call 860-OBESITY to speak to a nurse.
Check your BMI
Body mass index is a number derived from a person’s height and weight. Morbid obesity means your body mass index exceeds 35. For example, a 5 foot 8 inch man would need to weigh about 230 pounds to have a BMI of 35.
Some researchers say the BMI is misleading because it does not take into consideration racial and sex differences as well as muscle mass and bone density.
Calculate your BMI here.
Alix Boyle writes about health and home and real estate from her home on the Connecticut shoreline. The natural beauty of the shoreline makes her feel like she’s on vacation every day.