EXPERT > Doctor In The House

Weight Loss Through Surgery

By Dr. Racquel Bueno
Interviewed by Melissa Moniz
Wednesday - September 17, 2008
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Dr. Racquel Bueno
General Surgeon

What is your area of specialty?

What I primarily do is what is called minimally invasive surgery. So, instead of using traditional open surgery techniques, I use small incisions. I was also trained in robotic surgery. So I do all types of minimally invasive surgery and I also do obesity surgery (bariatrics). For the obesity surgery, I also use the robot.

Can you explain in more detail the different types of bariatric procedures you do?

The ones that are most common that we do are: the laparoscopic gastric bypass, which is done with a small incision and using the robot at Queen’s. There are two other procedures we do at Queen’s, which are the laparoscopic adjustable gastric band and the laparoscopic gastric sleeve. So there are three major types of procedures.

What are the major differences among the three procedures? And also, how is it decided which procedure is best for the patient?

For the most part, the bariatric procedures are for people who suffer from morbid obesity, which is basically refractory to all other means of weight loss. They have usually made numerous attempts to diet and exercise that have been largely unsuccessful. These patients, because of their obesity, have a lot of medical problems such as high blood pressure, diabetes, joint pains, sleep apnea and those kinds of issues. What they do is get evaluated by our weight management team at Queen’s. And then they are told about the different types of surgeries. So you have the surgeries that just cause a restrictive component, which means you basically limit the amount of calories a patient eats. So you can do that by making the stomach a lot smaller, for example, with the gastric sleeve. You basically make the stomach, which is the size of a football, into the size of a banana. Or you use a band, which acts like a belt around the stomach itself. This is wrapped around the top of the stomach and it makes a ping-pong ball-size pouch and it acts like a reverse tire, so we can access it and inflate and deflate it. So your brain thinks the food is just going into that pouch, and it then triggers signals that tells your brain you’re full. So you end up eating a lot less. Those procedures are purely restrictive, which means they are intended only to limit the amount of calories you consume.

There is another procedure called malabsorbtive, meaning it limits how much your body can absorb. Those are really drastic procedures.

Then there are other procedures that combine both the restrictive and the malabsorbtive, which is the gastric bypass. Gastric bypass has been the most studied and is the most well-known, and is the most commonly done across the country. And it’s actually the most commonly done at our program at Queen’s.

What happens is not only is there the restrictive part, because you can only eat the volume of food that fits in a medicine cup, but there’s also a bypass section of your intestine, so what you do eat that is fatty doesn’t get absorbed. Based on the patient’s profile, then we basically try to tailor which operation is best for them, because there are some patients who aren’t suited for certain procedures. There are limitations for, like, the band, where it doesn’t tend to do well for someone who is very obese. Ultimately we will offer our professional opinions, but the patient has to be comfortable with what they choose.

In addition, they see a panel of professionals before we even get to the point of choosing which surgical option and getting them cleared for surgery, because there are a lot of components as to why people are obese. There are sometimes psychological issues that need to be addressed. Surgery is not going to fix that problem. All these things are hashed out before they decide on the surgery.

This chart illustrates common types of weight loss surgery procedures

You mentioned that after the restrictive surgery a person is limited to consuming “the volume of food that fits in a medicine cup.” How is the person able to receive their daily nutritional needs consuming that amount of food?

We have a dietitian who is part of the team, because a person actually has to relearn how to eat. They have a very strict schedule, so they are able to get the amount of calories they need per day and, more importantly, a balance between the type of calories they get and the amount of protein. That is very, very key. There are also some vitamins they have to take.

Anyone considering the surgery needs to know that they have to be followed. It’s not like we do the surgery and that’s it. They have to be followed for a minimum of five years, and that’s because we have to monitor their nutritional status and make sure they don’t swing the other way and get malnourished. It may sound really small, but in the end they get a very healthy volume of calories and protein per day. Initially, we supplement them with protein shakes, but eventually they reach a point where they can get all their caloric intake from their normal meals.

Once a person reaches his or her ideal weight, is the surgery then reversed?

No. All bariatric procedures are irreversible, including the band. People have this false assumption that the band is reversible. What people need to understand is every operation is considered a tool. It’s only a tool to help lose weight. The band is reversible only if there’s a complication, and it’s not as big of an undertaking as reversing a bypass. But if you intend to use the band only until you’ve lost the weight, then that’s a fallacy, because something happened to get the person to that weight. So if you take away the tool to have them succeed at the weight loss then we see people revert back. The example we like to use is if you need a pacemaker, sure, it’s removable, but you still have the underlying problem that it was intended to help.

Can you discuss in what cases medical insurance covers the procedure?

If you’re morbidly obese and your BMI is higher than 40, then insurance companies usually cover it. And certain insurance companies will cover it if you’re in the severe obese category (BMI of 35-39.9), if you have major medical problems. So it just depends.