Dr. Kirkpatrick on Bariatric Seminar Presentation 6/18/26

Speaker A: You guys should all know Dr. Kirkpatrick if you maybe have bumped into him. But we send a lot of our patients to him and I asked him to talk about the bariatric program, that he's, uh, in charge of it. And, um, he was really. It's a real blessing to give us this lecture because he's been in surgery all day.

Speaker B: So thank you. Yeah, thank you, guys. All right, we have, uh. We ready to get started? Yes.

Speaker C: Yes.

Speaker B: All right, we'll do it. Well, I said. Yeah, uh, thanks for, uh, having me over here. Yeah. My name is Dr. Ty Kirkpatrick. Uh, been kind of in the St. John system now for about eight plus years. I did my general surgery training here in town at Oklahoma State, but then went to the fellowship and minimally invasive surgery which included, you know, bariatrics and kind of all things foregut and robotic and Baton Rouge. But, uh, I'm glad me and my family back here in the Tulsa area. So that's a quick background about me. And currently, uh, serving as the medical director for the bariatric program at St. John. But do all things general surgery. I mean, gosh, gallbladders, hernias, enjoy doing all that, but forget or, you know, hiatal hernias and stomach work and bariatrics is definitely kind of my passion and what I enjoy doing the most. So, ah, certainly want to kind of do as much kind of Q A today as questions come up that you guys have. Um, I know I've gotten to meet some of you guys from time to time. Come over, hang out with me for a month. You're always welcome to do that. Um, I think it's always great, kind of on the primary care side that we all kind of come to an understanding of how we're treating patients. It's kind of impressive sometimes how we can be on sometimes separate wavelengths. So just chit chatting and talking about how we handle patients I think is always important. So we'll get moving along here. Uh, as far as this presentation is a little bit meant to. Just to kind of educate, uh, patients. So, uh, I'll change up the verbiage a little bit for you guys, but I think it's important you guys just know what is being offered here. You know, uh, we do have a comprehensive metabolic and bariatric team at St John, so I take the lead. But I certainly use, you, uh, know, Dr. Cedric Griffin and Gina Anderson kind, uh, of focus, uh, in on more of the metabolic or the pharmacology side of it when they, when we need help. But I have my PA that works with me. And then there's just a whole, uh, dietitian and of course, uh, just coordinators and managers that kind of help serve the patients and progress them through and give them options. So I think it's a fantastic service that we offer at St. John. Uh, you know, just real quick on your guys' side. You know, when you're talking with patients, you may already kind of just know this, but I think in Oklahoma, we're just so comfortable with morbid obesity. We just see it everywhere that sometimes the family practice docs just don't really bring up the fact that, hey, if your BMI is over 35, you're gonna essentially die sooner than you should. Um, that's just the strong reality of it. That's kind of why that's one of the initial criteria to talk about aggressive options. And, um, you know, in this day and age with the GLP1 medications hopefully makes a little bit easier. But that 35 or greater with a medical comorbidity is the one of the first line, um, reasons, uh, why you could be a candidate for surgical options. And then a BMI of greater than 40 without anything is another indication for potential, uh, uh, surgery. Surgery. Uh, these are, of course, set by our societies in the metabolic and bariatric world. This is what I accept. Insurance is a different world. So, I mean, this is just kind of first line. Basically, some patients just don't have the benefits. And that's a frustration and an issue I know you guys probably deal with for a variety of reasons. But 35 or greater with a medical video and 40 or greater without any. They can be a surgical candidate. One caveat to that. Um, or maybe two, I should add now, is typically someone with a BMI of 30 or greater, um, but with severe diabetes, not controlled. Really, that patient is an acceptable surgical candidate to consider bariatric surgery. And nowadays I can go over and talk about briefly a little bit, but we do offer endoscopic, uh, bariatric options. I can endoscopically perform a sleeve gastrectomy. And that criteria is lower at 30. Basically, 30 to 40 BMI for endoscopic. So incisionless bariatric surgery is now being offered and we have a little time. I'll kind of talk about that. Um, just so, just so we're on the same page of, like, what these surgeries are that we're doing, um, you know, you know, we do all these surgeries in a minimally invasive way, or I do them pretty much 100% robotically. Now that's just. We use small incisions and we use the robotic technology for better visualization. Uh, more wristed, uh, more uh, articulation and wrist action. Um, just more, less need for me to have any assistance during surgery. So if anyone's been had the privilege of being in the OR and seeing robotic technology, maybe you've seen the benefit. But I just really enjoy being able to pass that along to the patients. And I feel like we just deliver more consistent results. But these are the three most common surgical options. The vertical sleeve gastrectomy. And it's still impressive to this day. Maybe no one in yalls room right now, but to this day I still, I hear uh, physicians talk about how there's like a physical sleeve I put over the stomach and it's like. Well no, it's not a, it's not anything. It's um. I don't know why the sleeve gastrectomy actually got named a sleeve per se. I mean, I guess it looked like a sleeve to somebody. But we are removing a large portion of the stomach, right indicated here. And then we have this narrowed lumen of the stomach. So really a better representation is like, hey, it's more like we're making a football shaped organ down to a banana shaped organ is one way to kind of think about it. And um, you know, most stomachs can be an NFL sized stomach stomach, once fully descended, it is quite an impressive organ. I mean it's just a thick muscular organ that can distend out and be quite large. And we narrow it down to like a more banana shaped organ. So from simplicity standpoint, it is very much a restrictive process. I mean that's what patients feel. Right? That is a, that is a behavior modification tool. Um, but the reality is, I mean it's, it's still got, it's still a metabolic surgery, meaning we are still having hormonal benefit with the sleeve gastrectomy. So you know, ghrelin lives in the stomach, literally lives here. And so removing it, we decrease ghrelin. And that's one of your. Right, that's what stimulates appetite. So with ghrelin being less, your appetite's less. And it does have a, I would say kind of a modest GLP1 effect compared to the other ones. But you know, that glucagon like peptide, which also improves satiety, um, uh, also of course improves insulin and glucose utilization. Um, you know, those benefits as well. So some of the general pros of why the sleeve gastrectomy might be considered for one of your patients is it is somewhat of a faster surgery, uh, overall considered a little bit safer. I mean, it's still surgery, uh, but it's, it's sometimes the higher risk patients, we don't get off the table quicker. It's a, it's a, it's a better surgery for that. Or maybe they've had lots of complex past surgery history in the past and they have a lot of scar tissue. I might consider that, um, essentially just with any surgery, we're going to have risks of bleeding, infection or blood clots, things like that. That's all like less than 2%. I mean, bariatric surgery is safer than any hysterectomy that's being done out there today. Um, but it's still, it's still a major surgery. I mean, it is what it is. We've just. Those complications rates are low. I think just one nuance with the sleeve I'd like to bring up with you guys is, you know, someone is heartburn or reflux because it's, you know, more narrow muscular structure. You know, things want to regurgitate up easier. Um, so there are plenty of papers that kind of show, hey, we have increased risk of heartburn after the sleep. So if your patient already has heartburn, like, you know, it's, it's kind of things that the sleep may not be ideal. I usually just ask a lot of secondary questions like, well, you know, how bad is it? You know, have you ever had egd? It showed esophagitis. Do you have a physical reason why you might have it? Like a hiatal hernia that I would fix at the time of surgery. Is it diet related? Do you remember being a lower weight without it? Because obviously heartburn is caused by obesity. I mean, that's a dietary habit. So just because they have heartburn doesn't completely preclude them. But sometimes with someone with a long standing history of heartburn reflux, obviously we, um, we, uh, might, uh, need to consider that. So the ruin white gastric bypass is kind of the obvious. The one that's been around the longest, the one that literally still freaks a lot of people out. Just um, they consider it just a big surgery. And I mean, it is. But again, complication rates, you're so talking about less than 2% of most issues. And it works. We do create a restrictive effect. We kind of go from that football shaped organ more to an egg shaped pouch of the stomach. It's divided off and separated off from this bypass stomach But I'm not physically removing anything at this point. Like everything stays in the abdomen. So um, we divide that off and then we go down to the small intestine at a very particular point, usually uh, about 75 centimeters from the ligament of trites. And we divide the small bowel and then um, bring up a loop of um, that jejunum up to the pouch. So food travels in your small pouch, you get full, the restrictive effect and then gets travels down this, what's called the roux limb where all the food is uh, going down but doesn't meet up with your bile or gastric juices. Everything that breaks down your food to get fully absorbed until much farther downstream where we made a reconnection. So um, obviously we're bypassing a large portion of your small intestine and your stomach. And so there's going to be a malabsorption component. And that malabsorption component is needed to help lose weight. Um, on you guys side. And you know, I guess my side obviously worrying about vitamin deficiency as possible, um, we do have them on bariatric specific multivitamins. If you ever just compared kind of some bariatric multivitamins to some of the other counter ones, you'll probably just see a little higher levels of the B vitamins, um, things like that. Um, so, but, but there is just higher concentration of some of the vitamins in them. And so we, our program always gets everyone set up with them. Um, Centrum Silver is one over the counter, uh, one that we feel like is acceptable for bariatric patients. As you pick up bariatric patients, you know, that have been on Flintstones or for, I don't know how that continues to be a thing, but they go on Flintstone vitamins afterwards calling it good, at least recommend like a Centrum Silver. Um, but there are definitely tastic barrier, uh, other bariatric multivitamins out there available if they wanted to look into it more. Um, so yeah, I guess, you know, there really is one of the bigger effects of the rheumastric bypass is more the profound GLP1 effect that it has. This is the OG of why all these medications are out. Like this is the original guy that like why are these people so successful losing weight? I mean it's because they have such a profound GLP1 effect with the bypass. And so we treat the diabetes very effectively with the bypass and the satiety and everything lasts longer with the bypass. So statistically this is just an overall uh, more successful surgery long term compared to the sleeve gastrectomy. I, ah, still, I'm on this page still with all these risks, as always, risk of bleeding, infection. You know, we talked about the vitamin deficiencies concerns there long term. That's where I have more of a healthy respect for the bypass. I mean these bowels can rotate and twist and cause bowel blockages. Um, the connection sites between your gastric pouch and your roux limb, they can form like ulcers or stricture down. So again, big, big, big thing this, that they cannot smoke. They cannot smoke. It's not a good reason to smoke. We haven't found it yet, but they cannot smoke. They will, um, well, I guess what? Ulcerative colitis. I think smoking helps ulcerative colitis, if I'm not mistaken. Believe it or not. I have to chat so you can do that later. But smoking is bad for about everything else, including bypass patients. They can bleed, perforate ulcers there at that connection site. And uh, um, so yeah, no smoking and no ibuprofen use, NSAID use, um, you know, no prolonged inside use. That's another reason they have problems there. Um, and really like I said, I, or I'd really like for you guys to stop me anytime and ask a question. I'm just kind of plowing through here. But I, hopefully this isn't uh, hopefully teaching you something at least on our side and then kind of touching base on some things that might be pertinent for you guys as well. Again, this isn't really a newer surgery. I mean uh, uh, you might have all heard of something called the duodenal switch. Um, that's been around for a long time. Um, we've kind of modified it to be safer and a more still very effective surgery. So we now have created this single anastomosis 1 ileal bypass, aka the Sadie, aka the modified duodenal switch. So um, sometimes I call, I, I tell patients this is the sleeve plus. We do a sleeve gastrectomy first. So they get that restriction effect from the sleeve, but then we basically create a malabsorption effect at the end of their sleeve gastrectomy. The first portion of duodenum we bring up, we just bring a loop of bowel up to that portion of the duodenum and we bypass a significantly more amount of small bowel. So it's just greater malabsorption still with a restrictive effect. And um, there's about 300 cm of absorptive bowel left, which seems to be be about the sweet spot where we just don't run into consistent, just, you know, terrible, uh, dumping syndrome or just severe vitamin deficiencies left or right. But there's a, this should be a more powerful malabsorptive procedure than even the bypass. Um, and so, you know, hey, it's even better blood sugar control. Long term, it's even better weight loss, it's just more surgery. And so it's kind of a tiered effect here where the sleeve is kind of, hey, quote unquote, the safest, um, can certainly have a lot of success. But, um, for someone who loses £100 with the sleeve, we'd expect more like maybe 115 with the bypass, um, maybe 130, 140 with the Sadie. I mean, that's kind of one way to kind of think about it. Like there's just a gradual increase of potential weight loss. Um, I typically reserve this Sadie, um, for patient higher BMI, patients that are diabetics. So BMI greater than 50, um, who's a diabetic. I would lean towards probably suggesting this as the one surgery to um, really help them long term. So even though it carries, you know, always had a little bit higher risk, you know, usually these patients are coming to me pretty desperate. I've tried everything. Um, and uh, this is still statistically the most powerful option to surgery is still statistically the most powerful option for long term weight loss. Um, the weight loss medications are fantastic and have helped a lot of people. Just in my view, I think it's helping more of the still lower end on the obesity rate and, you know, people with access to them. So there's still a lot of limitations to the medications and as far as what your patient would go through. Again, all these surgeries are about, you know, Sleeve is about 45 minutes surgery. The bypass is about hour and a half. The SADIE is about an hour and a half surgery. They come in and stay one night in the hospital. I mean, 99 of them go home the next day. And of course we're just looking out for some common symptoms. We try to. I mean, most people should be able to get back to work at two weeks. I mean, gosh, they're pretty functional at a week out, but back to work at two weeks is recommended. Most of that is, hey, the first week's kind of more of a physical recovery. The second week's more of a mental recovery. I mean, we're asking a lot of these patients, um, they're really trying to focus on, on their fluid intake. Water, water, water, water, water. And then how do I sneak in my protein, get my protein, protein, protein. We have specific goals for them to reach, um, which is usually 70 grams of protein those first couple of weeks. And uh, you know, so it's just a lot. And so we kind of have them take two weeks off to just take care of themselves, focus on themselves. That's kind.

Speaker A: Doctor Patrick, you said 70 grams of protein per, per day is the target.

Speaker B: Yep, yep, yep. That's kind of the minimal goal we have for our patients after bariatric surgery is 70 with really closer to 90 once they get, you know, farther, farther out. Especially our, the SADIE patients. I mean from a simplistic, simplistic standpoint of dietary instructions to patients that we preach on our side, um, again, this is very shotgun style, but I mean it's, it's a high protein diet, right? Ah, you guys have probably seen that along with some maybe discussions or training about the GLP1 using GLP1 medications. It's um, a high protein, low calorie diet is what most Americans should be on to successfully potentially lose weight. And 70 grams is kind of a shotgun kind of answer that covers most people. Um, usually our dietitians do more math calculating, you know, caloric intake and their macros. But 70 grams is that minimal goal most patients try to reach. But honestly, the more the merrier. These patients, calorie counts are commonly around 800 the first, um, you know, four to six weeks and they get to about a thousand to 1200. 1200 probably being the upper end of the max. Most of them maybe can take in or should take in to have successful weight loss. But if you're getting thousand calories in and uh, over half your calories are from a lean protein, you can, you can do very well, be very safe, um, nutritionally and, and you know, lose the weight for sure. See I might, um, yeah, please, uh, questions, answer, please ask any questions. I was just uh, kind of had a different slide here. Just to kind of let you guys know of, kind um, of again newer options that I've been trained to do. I was actually trained to do this eight or nine years ago in fellowship. I just never really got around to be able to kind of get going. But we are offering endoscopic sleeve gastrectomy options now for patients. And again these are for patients typically that can be at a lower BMI, you know, down to 30. Um, this is a, ah, this is one of the procedures I feel like really works hand in hand with someone who's might be been on GLP1s but hasn't quite reached all their success or is willing to continue GLP1s, you know, long term, um, that this might help, but the endoscopic sleep gastrectomy is literally where we go in with um, the endoscope. I don't want to play this whole thing, but see if it shows up on yalls end.

Speaker A: What are the kind of complications you would see from this procedure compared to the other ones?

Speaker B: Well, obviously, you know, without having incisions and having to, you know, be inside the abdomen, um, we are avoiding, you know, a lot of those complications. But they, they patient, they can still have bleeding. We are going and taking full thickness bites. It's possible to get the spleen, it's possible to get vessels. That's obviously very rare. You're talking about pretty low chance. But you see in the video here how we kind of go in and kind of are making uh, big purchases and just suturing on the inside of the stomach to recreate um, what a sleeve gastrectomy would look like from the inside. So they can get bleeding, they can have a lot of pain, but you know, it's, it's basically outpatient. They go home the same day. They do recover overall quicker. Um, so it is, um, and uh, it is definitely a safer procedure. And so I, uh, think it's kind of good for those patients who maybe never wanted to think about surgery but want something more aggressive. It might be good for someone who we can't go into the belly because they have so much scar tissue. Maybe this is a better option. But you can see here they had a big merit trial, um, and they, you know, they lost about 13 to 15% of weight loss with it. That's pretty, pretty good. But you know, hey, I know the GLP ones, um, uh, are showing up to 15, 20% and that uh, the newest one, retatratride. I don't think I'm saying that right. I mean, gosh, it's like 25, 30 weight loss. It's quite impressive. Um, those are clinical trials, um, real life trials. We haven't quite seen same results with the medications, but um, yeah, it's a exciting way to offer really. I view the endoscopic sleeve as just someone who's always been kind of terrified of surgery, was never going to do surgery, but needs something still more aggressive. They may consider this as an option.

Speaker C: Dr. Kirkpatrick, the. So you don't get the like malabsorption effect with doing the endoscopic option and like how, how much difference, I guess in the Weight loss, does that seem to play?

Speaker B: I mean, I think it, it plays a, uh, a significant amount to something to think about. I mean, again with uh, uh, the physical. It is, this is definitely more of a behavior changing only procedure. Like it creates a physical restriction where you do get full quicker. But we're not seeing the incretin effect Again, the GLP1, the gut hormone effect. I just don't, I don't. We don't see within the scopic sleeve. So it's, it's definitely, you know, underneath the surgical approach as far as, as far as return on weight loss. But, uh, there are definitely lots of patients who, again, I think it, I mean, gosh, just to put in perspective, we only operate on 1% of the population of, of obese patients that qualify for surgery. So, you know, there's 99 of patients that qualify for back surgery, don't undergo surgery. Right. So, uh, so there's a big gap there of like, what are we offering these patients? And medications are increasing and then surgery is trying to become, I guess, less invasive and that's where the ESG kind of falls into. So, um, still good weight loss results. But 13% to 15% of their total body weight loss is kind of the general expectations versus the sleeve gastrectomy is around 20%. The bypass is around 25%. The SADI can be 30%. So those are rough numbers, but easy way to think about it.

Speaker C: Thank you.

Speaker B: And yeah, malabsorption again is, I mean, it sounds like a scary word, but it's, it's the metabolic changes that are going inside our body that promotes weight loss. Um, that's happening. So it's less about. We really just. I clinically don't see a lot of malabsorption concerns. I know out in the world there's patients who maybe had the bariac surgery 20, 30 years ago, or maybe they quit following me and they're only seeing their primary care doc and they're having some, uh, vitamin deficiencies, but it's just kind of rare. If they're compliant with our multivitamin regimen and compliant with. Even if they're eating smaller amounts or eating high quality food, smaller amounts, for them to have real consistent, you know, malabsorption vitamin, uh, deficiency type issues.

Speaker A: Is that vitamin important to continue in

Speaker B: the hospital or is it okay to be off it for a week or so? We purposely just wait a week after they got so much else going on, we just restart the multivitamin about a week out after surgery. So, yeah, I mean, that's not of a critical importance, uh, to be on it immediately.

Speaker A: I think what he's wondering about is when we admit patients who have had gastro.

Speaker B: Yes.

Speaker A: Um, the multivitamin, I think we. I don't know if it's on formulary. Is there a specific name or.

Speaker B: Um, well, ah, as far as the tablet I'm not actually aware of. No, we don't really. We don't. I mean, it's just that they would just take their usual multivitamin. Um, problem m. In the hospital. I mean, of course there's the banana bags that um, can be offered, you know. So in the hospital it's good conversation of when to be concerned if someone's had, you know, bariatric, the ruin white gastric bypass specifically. So again, this is also important. You know, I think some people, they've had the sleeve gastrectomy. Everyone calls it a gastric bypass. Sleeve gastrectomy is not a gastric bypass. Like, your level of concern should be a lot lower of some severe vitamin deficiency. With someone with a sleeve gastrectomy, they have their duodenum intact.

Speaker D: They have.

Speaker B: Have their small bowel intact. Um, unless they just are just not eating anything. But with some of the rheum gastric bypass that maybe came in kind of already frail and sick, you know, checking vitamin levels do become more important. And particularly, um, I would always caution you guys to be thinking about, uh, vitamin B1 or thiamine deficiency on these patients coming in. You know, if they come in with nausea, vomiting, other illnesses, that thiamine deficiency a could be driving their symptoms. I mean, um, but they, they definitely need to be repleted of their thiamine quickly to prevent, uh. Um. Warnickes is kind of one of the bigger concerns there. So, um, uh, that would be one patient you'd want to get back on multi. Multivitamins if they've already coming in pretty depleted, maybe from another medical illness, maybe directly from the bypass. But that is something definitely do consider. Doctor Katrick.

Speaker D: Um, I've got one patient. I, I think there are others where it's like they, they have a bypass and then they either gain the weight back or they kind of have halted weight loss. Um, maybe their lifestyle changes aren't the best. Um, and then they're in our clinic and they're asking for like, medications and maybe they're on a GLP1 or something like that. So, um, after they've had the surgery, are there any like, restrictions or like pro tips on like further management? Should we get Them back to you. Should we go with the GLP ones? Like, how do we kind of go forward after they've, you know, got three, five years ago and they're still got a BMI of 41 or something like that?

Speaker B: Yeah, no, um, you know, great question. And I know a fairly can feel like a common scenario for sure. So, you know, weight, uh, weight recidivism or weight regain after bariatric surgery. Some degrees, inspectors, and that natural bell curve where they. At, uh, two years, they usually lose their maximum weight and they might regain a little bit of it. Hopefully it tapers off. But those who have truly started regaining all their weight, um, you almost got to kind of restart from scratch a little bit. I mean, they definitely need the dietary education. They need simple support in that way. They need to understand they have to increase their physical activity. I mean, this is painful. Conversations, I know, maybe seem hard, but that is like the baseline. That is, that is, we have to have some sort of foundation to stand on is like, can you start consuming a high protein, low calorie diet and can you go for some sort of a walk? Can you, you move somewhere, you know, but yeah, adding on, definitely having a plan to add pharmacologic, ah, assistance I think is very acceptable after bariac surgery. There's really no contraindication to adding any of these medications onto someone who's already had bariatric surgery. Um, the sleeve gastrectomy in particularly, we, we feel like that weight loss surgery effect has really gone away at a year, year and a half. Um, maybe that's why we see a little bit more regain with the sleeve gastrectomy. If people haven't fully bought into behavior changes. Um, but even with the bypass, anything adding them, adding on weight loss medications is important. Think about this, okay? I mean, morbid obesity, right? It is a, it's a chronic disease, right? So it really never goes away. It's certainly complex. It's a complex chronic relapsing medical disease. Okay? So the idea of us doing one thing and treating it completely for a lifetime is foolish. It's just silly. I mean, that's just what it is. So, yes, we got to start with diet and exercise. Yes, you got to start doing behavior changes. Um, yes, maybe medication is first line trial. Uh, yes, maybe we have to add surgery on board and maybe we have tons of success. Uh, maybe it starts to become stagnant. We have to get back on medications. It's a chronic relapsing medical disease. So, um, it's almost like we can Never truly smother it out because it's going to be there. And uh, I think that's, I start, I try to have honest conversations with that about patients in my office because setting expectations is important. Because I think what, historically, I think what may have happened, I hope it doesn't happen to a lot of my patients. They lose a lot of weight the first year, Year two, it starts coming back and they just throw your hands up and they're like, I'm done. I can't, I can't believe this happened. I'm done. No, like they need ongoing support, education options, which is again probably why this, um, you know, the endoscopic sleeve is kind of interesting as far as talking about patients. As far, you know, this is a nice little slide just kind of showing. Hey, these are the layers that we might have to offer patients. You know, we gotta talk about diet and exercise, we gotta talk about medications, um, and if they're not quite ready for surgery as sleep endoscopic. So yeah, it's a, uh, it's a whole thing. That's why I know in the primary care doc world it's hard. You're battling diabetes or battling hypertension, you're dying, sleep apnea, pcos, whatever, you're battling all that. We know the root cause is, it's obesity. But it's really hard to step back and have that 20, 30 minute conversation like, well, what's your macros here? You know, how much, how much protein you're getting in? Oh, uh, you know that, that juice box that you're drinking there is probably not the wisest. So I don't know what we, I don't even know what the question was at this point. But

Speaker D: thank you.

Speaker B: I could definitely go on and talk a lot about, ah, all things bariatrics. I think it's uh, I mean, I think these patients just, they just need more. Again, it's just a chronic disease. Think about like cancer. Like when the world. Here's what I think I was getting back to, you know, cancer, right? We have a neoadjuvant, uh, adjuvant treatment for cancer, right. With obesity, I think medications you kind of need to think about like adjuvant neoadjuvant therapy potentially around surgery. Like sometimes we need the medications to get us down to make surgery safer. And then a lot of times we may need uh, medications after surgery to kind of keep it, keep uh, keep it down. You know, that's, that's all very a realistic approach. So it's just not all. This is one thing and nothing. I think that was my point. I was trying to come back back to, um. Well, sometimes you got to think about like this, like a, like a cancer.

Speaker A: You ever do a ruin? Why after someone's have had a sleeve or esg.

Speaker B: Yes. Uh, the. One of the nice things about sleeve gastrectomy does keep doors open for revisional surgeries. Um, so converting it to a bypass. Yes. Can definitely be done. Or converting it to that. Sadie, that modified duodenal switch can be done after the sleeve. Uh, honestly, my. When I first started doing those modified duodenal switches, Sadie's, I, you know, a lot of times these patients, we have BMI of 65 or greater. And I would do justice sleeve first, mainly just, uh, because it's just safer to get them down maybe that. Maybe their BMI goes from 65 to 45. And if they were still having medical issues with their, with their weight, we might add the Sadie on and get that BMI on down past 35. I mean, that's kind of my initial approaches. I, I'm kind of now offering it more just as the first line surgery, but extremely high BMIs, which is 65 or greater in my mind. Um, they propose it provide a really unique challenge in surgery. Like, it is just hard. Their fatty tissue is literally just like Rick inside. So it's, it's, it's. Everything is more challenging. Um, so sometimes we just need to get a surgery done as safe as possible and come back another day to complete the process if need be. I'm not sure what else it's going to show here, but, yeah. Any other questions come up? Can you, uh, if you do the endoscopic procedure first, can you go back later and do, um, revisions on that pretty easily? You can. Pretty easily. I don't know about pretty easily, but you can. Those sutures are permanent. We'd have to kind of pluck them out. Um, but yes, it, uh, can be revised later. Uh, it certainly can be. So. And I can actually, um, the endoscopic options, if they've had a previous sleeve but they quote unquote, stretched it out or lost restriction effect, I can resleet them endoscopically or if they've had the gastric bypass and their gj, the gastrojeunal anastomosis that, that opening there, if it can get too wide and dilated, I can, um, suture that down close to recreate that restriction effect. And those, I mean, people that do. I mean, they've some quite a bit of promising effect with that. So there's always revisional options. Um, there always are, there's more challenging, Everything's gonna be a little bit higher risk. And so I have pretty honest conversations with patients, but, um, they're definitely possible. And when I say higher, they're higher risk than, again, the 1 to 2% risk of something happen. Maybe we're in the 3 to 4% risk of something happening. So in surgery world, once we get 3 to 4% surgical risk, that's actually a little high than we wouldn't want to be in. Like, we, we feel like for the most part, we have, uh, pretty good safe outcomes despite. I know you guys see tears from time to time. Statistically, we just don't have that many complications after bariatric surgery.

Speaker A: Thank you.

Speaker B: But great questions. I mean, I know, um, you know, for lab wise or like patients you're thinking about working up. You know, we always, on our side, we always look out for endocrine reasons or other reasons why they are failing to lose weight. I mean, so we always kind of just, we always appreciate the thyroid's been checked out, you know, and things like that. Um, uh, so those are, those are things we kind of look into that can be done kind of more on the primary care side to make sure that they're good, good to go, um, that there's not another reason or any other hindrances than losing weight.

Speaker D: Dr. Kirkpatrick, some of us, um, work overseas at different points. Are these surgeries, do they look different around the world, um, in a major way?

Speaker B: Well, there are in other countries such as, I know India and things like that. They are. There are definitely a few surgeries that are essentially behaving the same. But there's the, the something called the Omega bypass, which is like a gastric bypass with just a single loop going up to it. But bottom line is most of the principles of concerns about, um, vitamin deficiencies and stuff like that are going to be very similar. Uh, I don't think that there's any unique complications. Even if they do a surgery subtly different over there that they would have.

Speaker D: Thank you.

Speaker C: And if we put in referrals to the, um, like is it to the under healthy lifestyles or should we put like referrals to patients in to see you directly? Or what's the best way for our patients? And also is what's the sooner care situation? Are they covering it as well?

Speaker B: Yeah, uh, healthy lifestyles for everyone that wants to do bariatric specific healthy lifestyles is how they want to do it. And within healthy lifestyles, There should be a medical only option and then a surgical option. Click button on there what I'm told. So obviously all the surgical ones do come to me for evaluation. So maybe the patient's on the fence, but they want to talk to a surgeon. I'm happy to always just talk, talk with them. They're all going to go through a medical route. I mean, you know, right. This is a, usually a four month process. Um, making sure they get dietary education, they get medically cleared from cardiology, sleep lab, uh, psych, um, so, uh, so they all, they all go through some sort of a medical process or sometimes if I feel like they need aggressive medical weight loss beforehand, I might a send them back to you guys to have a thorough discussion about pharmacologic assistance. Um, the medication is just something I've decided in my office. It's just, it's a lot for a surgeon to take on when I'm like, you know, worried about kind of surgical part of things. So I leave the medical stuff to the experts, smarter people, they can let you guys kind of help with that. So I just send them back to you or maybe on to Dr. Griffin to kind of have uh, assistance with medications preoperatively. Yeah, Healthy lifestyles is the, a way to send patients over to talk about all things bariatric, sooner care, Medicaid options, all the, all the plans. Uh, St. John's only one of two places in the state that will do Medicaid patients. So yeah, we, I see a lot of Medicaid patients, um, uh, and I think that they're all covered, you know, Aetna Humana and there's a third one out there. Um, our sooner care options for them now. And even regular Medicaid, which I guess still exists, we see them all.

Speaker A: So that's great.

Speaker B: Yeah, medications, um, unfortunately the Medicaid population, they don't have access to the medications, which is kind of too bad. Um, but again, they've done the math. I mean, surgery is still the cheapest way to treat morbid obesity. No one wants to talk about. It's the most aggressive way. But one time surgery is still the cheapest way to battle what they got going on. So most, um, of the insurances kind of get that. Um, Medicaid has not figured that out. So we'll keep doing the surgeries.

Speaker A: You said surgery is the cheapest.

Speaker B: Yeah, surgery is the cheapest. Yeah. So yeah, Medicaid, Medicaid knows that is what I'm trying to say. Medicaid, I mean, they uh, I mean the Medications are just super expensive. And again, how do we define morbid obesity? It's a chronic relapsing medical problem. You can debt when you start someone on these medications they're not ever supposed to come off of it. It's like treating hypertension, thinking oh yeah, after six months of treating your hypertension. Amlodipine, 10 milligrams that I'm on. I've been on it forever because, because I need it and I'm, I'm a buck 80 dripping wet. So anyways it's just kind of like sometimes it's, we gotta think of more of a chronic medical disease. And um, and patients need to be aware that when we start these GLP1 medications it's meant to be lifelong. And that's what we're seeing. Right. You guys probably see that a lot like they got on it and when they came off it, weight came right back or um, like couldn't afford it or poor access to it. Unfortunately there's just lots of limitations to appropriate care for morbid obesity.

Speaker A: So it's not inappropriate. If we've tried the lifestyle with our patients and they're a Medicaid patient and they can't afford a GLP one, they could get covered by Medicaid to get bariatric surgery. Correct. Even if we have medication.

Speaker B: Yeah, we, yep, we see a lot of Medicaid patients me and the OU program OU sees a lot as well. Um, it's probably, I mean gosh, two years ago it might have been like 5, 2%, 5% of my practice. I mean now it's probably about half and I initially was almost, I was always worried about the Medicaid population because does have access to protein drinks and you know, can they go afford the right foods? I asked usually ask them directly, do you have about 50 bucks of disposable income for protein drinks and multivitamins? And most of them do. I just haven't, we actually haven't just encountered that problem. So I, I what I had bias against them because of that and I was incorrect and they've proven me wrong. So um, they do have a little bit higher ER visit bounce back rate. I mean they will use the ER like their primary care docs. So that's one thing we're working on to help them get resources before just going to the er but other than that they've all done really well and um, m just yeah, it's always a blessing to be able to take care of them. So very rewarding on my part. I mean, mean it's just, that's really one of the coolest thing to see the six month, one year follow ups and people just be ecstatic and happy and have loose skin.

Speaker A: All right, any other questions? Or we.

Speaker D: Oh, I guess, um, one more. You just mentioned at the end of the loose skin part, do they, um, what's the rate at which people try to go forward for like a cosmetic thing after bariatric surgery? And is that something that you think is recommended or is that like going to be a problem? Um, if they regain the weight, how

Speaker B: does that work out? No, uh, yeah, excess skin is definitely kind of a sign of success. Very common. Um, but all my patients probably are going on and seeing the plastic surgeon about 18 months out. Our recommendation is a 18 months out from surgery. Um, now a lot of people go a little sooner than that. But the key with that is basically they need to have their weight loss complete. You know, you don't want to go see a plastic surgeon and lose 40 more pounds after a skin removal surgery and have more loose skin. But, uh, it's pretty common and there's a cosmetic part to it that's usually the under the arms or obviously breast augmentation. But the panis, the excess scan of the abdomen is usually the biggest problem. So if you can document wounds, irritation underneath there, or if it just hangs down a certain amount, insurance will pay for panniculectomies. So it's not really cosmetic, but functionally they can look really good in a T shirt and just be very happy, more functional. So that's a very common conversation I have at one year out, um, and we send them to the plastic surgeon. I mean, I did that in training, but I just feel like that's a lot of skin and just everyone needs to go see the person who does it the most and does it the best. So we send them all to a plastic surgeon with St. John, it's Dr. Collins, uh, Patrick Collins sees them the most. But there's, I think Dr. Um, Hugh is there as well. Ah, did fantastic job. Great question. Answer any other question. You guys got anything else out there?

Speaker A: I have one quick, um, insurance question

Speaker B: for plastics after bariatrics and, uh, if they need plastics, do they typically cover that with sooner care or private insurance? Again, the panniculectomies. Yes. Again, the tummy tucks. That's like the Florida Lee, like where they make like they really tighten it, like a vertical incision and then a transverse incision and they bring that, that contour, that abdomen. That's cosmetic. And cosmetic, no insurance covers quote unquote cosmetics. So um, it basically is just what's called a paniculectomy and that's where they just take the excess skin at the bottom of the panis and they just one little, one little strip. Um, I mean Dr. Collins talks about, he does it pretty cosmetically well and he'll talk to the patients about the options. But yeah, for your Medicaid patients it can be covered. Uh, but those typically those wounds or irritations or something like that has to be documented to help with that. The loose skin of the arms that's all always going to be cosmetic. So pretty much there's just one skin removal option to be covered under insurance and that's maniculectomy.

Speaker A: All right, thank you.

Speaker C: Thank you.

Speaker A: Yep.

Speaker B: Thanks guys. Hope to see you around. Stop me in the hallways or come hang out if you guys want for a month. So try to have.