Chapters Transcript Dry Eye Update 2026 Course: Current Concepts of Ophthalmology 2026 I'll be speaking to you about the um bariatric surgery treatment options. Uh, some of you are very familiar with them, and some of you may not be. So, um, I'm just going to um just go over uh what's available now and, and some of the data um that is associated with it. So, um, this is my disclosure. Again, the criteria for a bariatric surgery treatment, and this is insurance coverage. The ASMBS has modified this criteria to incorporate uh lower BMI, but also um the impact of um of Descent or of origin, meaning Asians have a lower BMI um indication because of their predisposition for developing comorbidities at a lower BMI. Uh, so, um, but the the all the insurance. Still uses criteria BMI of 40 or greater. Uh, otherwise, um, someone who has a BMI between 35 and 39.9, uh, typically have to have some serious, um, related comorbidity that's, uh, magnified by their obesity. Uh, in addition, there has to be, um, some proof of, of, um, Try a trial on losing weight in a non-surgical manner, uh, and, and evaluation by a nutritionist and a psychologist. How does surgery work? There are really two ways that they work. There's two categories of surgery. There's restrictive and malabsorptive. The restrictive operations really limit how much food is ingested. And the, the three main operations that fall under the restrictive operations are adjustable gastric banding, otherwise known as lap band, uh, sleeve gastrectomy, and ruin my gastric bypass. I'll be going into each of these, uh, just in a moment. Uh, the malabsorptive operations, mal meaning not, so non-absorptive or decreasing absorptive, um, operations, they limit the digestion and absorption of calories and as well as nutrients, and the operations that fall under that category is the one anastomosis gastric bypass, also known as OAGB. Uh, biliopancreatic diversion, otherwise known as BPD, uh, biliopancreatic diversion with duodenal switch, uh, also known as a DS, and single anastomosis duodenal ileostomy, which is Sadie. It's mouthful, they're very Anatomically driven descriptive operations, but you'll, you'll hear OHEB, BPD, DS, Sadie thrown around, uh, but I'll show you a little pictures so that you have an idea of what they mean. They're all done, uh, pretty much now, uh, in the country in the world, they're done laparoscopically or robotically, um, and they're all done under general anesthesia. So the normal anatomy, primarily the operations are going to be involving um the stomach and the small bowel. Uh, the esophagus and the colon is not, is not really affected. And um there's multiple incisions uh nowadays there's anywhere between 4 to 6 or 7 incisions that that are necessary. So let's talk about the restrictive operations, um. The most common being sleeve gastrectomy, followed by the gastric bypass, ruin why gastric bypass and lap band. And really the, the, the way that that people lose weight, a lot, there's a lot of misconceptions out there. A lot of patients think that they're going to be forced not to eat, not being able to eat, but still being hungry, and, and vomit. And so, uh, it's really important to let them know that really it's that surgery will decrease your appetite. It will increase satiety. It'll provide some behavioral modification, encouragement, um, by, uh, really requiring them to eat slower, to chew better, otherwise they may have some side effects from these operations. There are also some side effects and uh such as dumping syndrome with very high concentrated sugar intake that can happen with primarily the Rowa gastric bypass and the sleeve gastrectomy. And of course, there's going to be a texture issue if the, the, the stomach, uh, is, is decreased in size, uh, and there's gonna be some dietary modification that patients will have to, will have to make. So, again, focusing on the restrictive operations, and this is just from least invasive to most invasive. The adjustable gastric band continues to be available on the market, was very, very popular in the 2000s, and now is much less popular, but it still exists and is available, and it's essentially an implantable device, which, again, I'll Go over in a few slides, the vertical and so it's an implantable device that has two components. Um, the vertical sleeve gastrectomy is a misnomer. There's no sleeve that's being put in. Uh, it's essentially a partial gastrectomy or removal, um, of 80% of the stomach, which is then removed, and then the the remaining. Stomach is tubular in shape, uh, similar to a sleeve, so, um, that name sort of stuck and then the ruin why gastric bypass, um, is creation of a small, uh, stomach, um, the and rerouting of the, of the, um, distal stomach and the proximal, uh, intestine. The malabsorptive operations again this is a little bit of repetition, uh, but then hopefully you'll remember um the one anastomosis gastric bypass is very similar to a gastric bypass except that the stomach pouch is a little bit longer and uh there's only one anastomosis which means that, uh, the intestine further down is brought up and uh brought up to the smaller gastric pouch. Pouch, but more of the intestine is bypassed, so it's malabsorptive. Um, the duodenal switch has, um, sort of a partial gastrectomy, uh, similar to the sleeve, uh, and, um, it has a ruin why, um, uh, bypassing or anastomosis where a significant amount of intestine is bypassed, so the distance between the stomach and the colon is much shorter. And this decreases um digestion and decreases absorption. The single um anastomosis duodenal ileostomy, or otherwise known as the ADD, uh, is sort of an offshoot of the duodenal switch, uh, and this is meant to be um a little bit less risky surgically, um. Risky, uh, because, again, we have our sleeve gastrectomy, but instead of creating two, connections here anastomosis, we only have one because this long loop of intestine is brought up, so there's only one, connection there. And in surgery, uh, the more cutting and reconnecting, you're increasing the slightly higher chance of some, um, complication related to that, that, um, reconnection. So, um, From 1990 to 2014, um, again, a little bit of an older slide, but, um, initially back in the 1990s, the most common operations were, uh, Roino gastric bypass, as well as an operation called the vertical bandit gastroplasty, which really, uh, has, has stopped being performed by 2000. Um, the gastric bypass uh had increased in popularity in the 90s, uh, primarily with the introduction of laparoscopic technique, uh, because prior to that, in the 9 prior to the 90s, everything was performed by open laparotomy. Uh, but in the 2000s, um, actually, the year 2000, the FDA, uh, approved the lap band or the gastric band, and that became very, very popular because it was, uh, much less invasive than the other, uh, alternative of the gastric bypass. And then 2008, 2010, um, a sleeve gastrectomy. Was described, uh, uh, CPT code was created, and now it continues to be the most popular operation if you go out to 2025. Um, the band has decreased in popularity and is, uh, no longer, uh, frequently performed, and the gastric bypass has stayed quite neutral. Um, sleeve gastrectomy is the, the most common operation being performed today. Uh, and as I said, we're decreasing physically, uh, the size of the stomach, um, and therefore, because the container is smaller, uh, then you get full with a smaller portion of food. But in addition, you know, there's been some, uh, much Research into the constitution or the quality of the stomach that's removed. And um there, there's a very large concentration of cells that pro that produce ghrelin, or growth-related hormone, which is yogenic. It's, it produces a hunger hormone. And so the The idea is that if you remove 80% of your stomach, you are significantly decreasing the ghrelin levels, and therefore, uh, appetite is significantly reduced. Um, the, the weight loss is, uh, is very good, uh, particularly in the first year or 2. Um, 60 to 70% excess weight loss, or otherwise 40%, uh, total body weight. The downside is that there is a risk of reflux, um, for, um, reasons that I'm not going to go into, but because of the mechanics uh that are that now the new stomach it has, then it can um increase the, the reflux. Uh, rate afterwards. Again, the suggested mechanisms are decreased ghrelin, decreased hunger, decreased caloric intake, decreased caloric load, uh, increased GLP, uh, and which leads to increased glycemic control. Gastric band is an implantable device, as I mentioned, it's, there's two components, um, and this band has a balloon that's on the inside, which can be titrated, can be tightened and loosened, uh, by accessing a reservoir or a portal that's underneath the skin of the abdominal wall. Um, and the idea is that it's compressing the vagus nerves, um, that's increasing appetite suppression. It also decreases the emptying of food through, um, from the top of the stomach to the lower stomach, and the idea is that the top of the stomach is stretching, the stretch fibers are firing soon enough, and therefore satiety is reached sooner. Um, the weight loss is about 40% excess weight loss. It's about, um, 25 to 30% total weight loss. There is a very important postoperative component to a lap band. You can't just put the device in and never see the patient again, uh, which you can do with the other, all the other operations. This is more of an interactive tool, um, where it's malleable. Uh, the patients do need to come in. And have their band tightened according to a visual scale that we use that will describe their level of appetite, their level of satiety, uh, and their weight loss. If they do not come back, the probability of them losing weight will be very, very low. Um, so patients are counseled that uh they really need to come in monthly for the first year optimally if they can to get this band tightened, um, uh, or loosened, or at least educated on how to use this device. Um, one of the benefits is that it's malleable. You can tailor it to the patient. A lot of patients, um, in certain cultural, um, backgrounds say, you know what, I don't want to lose that much weight. I want to lose 50 pounds so that I get the, the pressure off my knees. I don't want to lose 100 pounds. I don't want to lose 150 pounds and look really skinny and awkward like my, my friends. So this might be something that's more uh malleable. Uh, pregnancy, this is a great um option for women who want to get pregnant because There's no deficiency, nutritional deficiencies in the main, uh, that can uh provide risk to the fetus, uh, and also can be loosened or tightened according to how the, the, the woman feels during pregnancy and then afterwards. Um, it's good for travel, um, if there's someone has an illness, they need the band loosened, they're becoming, um, dehydrated, the band can be loosened, and there's no malalabsorption. However, it is very easy to manipulate. It is easy to blend all your food and, and just drink high calorie beverages. So patients really need a lot more education and um input into the success. Uh, it is very, it is reversible. You can take it out, um, less than an hour outpatient surgery, but the patients need to be committed to more follow up and the surgical practice needs to be more committed. Again, the suggested mechanism is vagus nerve compression, promoting appetite and satiety. They were my gastric bypass, um, again, the top of the stomach is, is severed and separated. Um, the remaining stomach is left intact, nothing is removed, and it is still viable and alive. Uh, it's still producing a lot of the digestive hormones. And the duodenum is bypassed and all the bile and digestive juices from the pancreas and liver are still intact, but they are reconnected, um, to be reintroduced into a, a portion of intestine that has been brought up to the gastric pouch. And, uh, this is a, a very, um, interesting sort of idea which has brought on a lot of the, um. Endoscopic, um, interesting devices as well as GLP-1 agonists. Um, there's a lot of gut hormone changes that occur here, uh, by bypass not allowing food to go into the the duodenum, uh, by promoting, uh, food to be in contact with the jejunum, uh, that is a little bit lower down, uh, unopposed with acid. So there's a lot of gut hormones that that get um enacted, uh, which may be contributing um to the weight loss. But um certain dietary issues that can arise, as I said, dumping can occur, so patients are counseled to avoid uh uh very high concentrations of sugar. Um, they need to take uh a variety of supplements in order to avoid malabsorption. It is a reversible operation, but it's a significant operation if one needs to do that. Uh, and again to just review, um, the duodenal bypass will increase GLP-1 and increase insulin secretion. There may be a bit of malabsorption that can promote calorie, uh, intake, uh, decrease. Uh, there may be a decrease in ghrelin, which also decreases appetite, and all this results in increased glycemic control. The malabsorptive operations um really decrease the, the distance between the stomach and the and the colon, so that uh there's less digestion, there's less absorption, not only calories, but also fat, uh, fat, um. Um, fat related, uh, vitamins, fat soluble vitamins such as vitamin A, vitamin D, vitamin E, and vitamin K. It does provide the greatest amount of weight loss, 80 to 85% excess weight loss, uh, which equals to about, um, 50 to 60% total body weight. So, um, these operations really are terrific for people who need hundreds and hundreds of pounds to lose, uh, but there's potential serious long-term nutritional problems that have to be monitored. And because you have this is the most involved sort of set of operations, they tend to have uh the potential for for greatest complications, and I reviewed this with you. Again, the Sadie is becoming a more popular, more talked about operation where um a sleeve gastrectomy is performed, um, the uh Uh, the duodenum just past the stomach is divided and separated, and then a loop of intestine further down, maybe 200 centimeters further down, is brought up and reconnected, so that there's a significant amount of intestine that's not being exposed to food. Food is simply going straight into the lower part of the intestine. Here's just a slide for your um for your um referral, but from least invasive to the most invasive, which is uh gastric band uh bypass, sorry, the other way around, sleeve gastrectomy, gastric bypass, and the intestinal bypass operations. The mortality, um, they're very safe. Um, we always talk about surgery having potential complications because nobody likes surgery and um a lot of people feel that this is not a medically necessary operation. A lot of patients feel very conflicted having surgery. Uh, and so when we say there's a 0.2% mortality, it, it's, it, it, it's sometimes it's viewed, and if they do have a mortality, it's viewed as, oh, she was a mother of three, and all she was a little bit heavy, and she had some knee problems, when in fact, that patient may have really been ill, um, and they had an unfortunate complication. So all I'm saying is that the mortality, uh, and the morbidity, the complication rates are low, particularly when you compare them to other operations, which I'll show you, uh, but, but they should not be underestimated, and, um, we talked to our patients about all of them. With the lap band, the delayed complications could be device, uh, related, such as the, uh, malpositioning of the band, band slippage, erosion, device malfunction, or weight gain. Gastric bypass, um, the delayed complications can be internal hernia where the intestines twist and become obstructed. It could be ulcerations, nutritional deficiencies. With a sleeve gastrectomy, reflux is the most common, um, problem, uh, and the malabsorptive operations, uh, their most common problem is nutritional deficiency. So long term follow up with these patients is incredibly important in order to remind the patients, educate them, and try to identify any early, um, signs of complications. Again, when you look at mortality, uh, bariatric surgery mortality is 0.05 to 2%, uh, as compared to total hip replacement, which is 2 to 3%, um, colon resection 1 to 3%, and coronary artery bypasses 1 to 2%. So in, in the main bariatric surgery remains, um, a safe operation. And this is just a comparison of the weight losses, and on the y axis is the percent excess weight loss, and I apologize, but our publications that had long term outcomes all used percent excess weight loss as opposed to 1% total weight loss. Um, so the most, the most weight loss is the malabsorptive operations, followed by the gastric bypass and orange, the sleeve gastrectomy in black tends to have a little bit of an equilibration after 5 years in the lap band. Um, provides, uh, the least amount, um, comparatively, but can remain, uh, quite good, uh, coming out. What this doesn't show you is that I think that regardless, because of the severity of the condition of obesity, um, I, I think that most of my colleagues would agree that I'd say 25 to 30% of patients who have any type of bariatric surgery is going to have some sort of weight regain. And that's what we're gonna be talking about afterwards, is, you know, how do, how do we now address that, and with the onset of all of these new medications and endoscopic techniques, how we can um utilize multimodal therapy. The effect on comorbid illnesses um has been really terrific. Um, I'm not going to, um, dwell on that, um, and we know that it really is, is very, very good on diabetes remission, but again, surgery offers a tool. It is not it and will never be a magic pill, uh, patients have to work with it, uh, otherwise they'll regain weight. But people who use this tool are among the happiest people on earth, as we've seen. So we do provide nutritional evaluation, psychological evaluation, uh, and medical clearance, um. And I just wanted to, uh, in conclusion, uh, obesity is a chronic medical illness. It has a long reaching consequences, and, and, uh, it's present surgery is the only present treatment that offers the best chance at sustained significant weight loss. Uh, there are different types of operations, and I think patients do best if it's they're performed within a multidisciplinary comprehensive uh program. I do have one final disclosure. Uh, my husband has had a lap band since 1999. Uh, he has, uh, now it's more than 1005 pounds that he's lost. It's probably more like 120, and that's about 9 over 90% excess weight loss. He's never had a revision, he's never had a conversion, he's not, he still has the same old band in there. And um he's done great, so he's really taught me a lot about the the struggles um of of being obese, um, the frustrations of trying to lose weight on your own, and I've also learned the ins and outs of a lap band. So, um, with that, um, I would like to thank you for your attention, um, and we will save all of our questions cause we'll have a panel afterwards. Published January 30, 2026 Created by
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