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Bariatric Surgery (transcript)
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Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association; an Association of independent Blue Plans committed to better knowledge leading to better, more affordable health care for consumers.

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(Dr. Peter Salgo) 
Welcome to Second Opinion where each week our health care team solves a real medical mystery. When we close this file in a half an hour from now, you'll not only know the outcome of this week's case, you'll be able to better take charge of your own health care. I'm your host Dr. Peter Salgo and our story today concerns Sophie. Now you've already met our special guests who are joining our cast of regulars Primary Care Physician Dr. Lou Papa and health reporter Kat Carney. No one on the team knows the case. It's right in here. It's time to open the chart and get to work. Let me tell you a little bit about Sophie. Sophie is 37 years old, she is 5' 8" tall, and she weighs 287 pounds. Sophie's a nurse on a surgical floor in a major hospital, she is active, she's mobile, she's a single mother it says here of 2 children, she keeps everything in her life up and running; she juggles everything and the children are of normal size. Now a surgeon that she works for says that her being overweight is setting a bad example for the patients in the hospital and he suggests that she consider surgery to help her get her weight under control. By the way, what kind of surgery are we talking about here?

(Dr. Lou Papa)  
Weight loss surgery or Bariatric Surgery, which is surgery to promote weight loss. It kind of affects your eating habits basically.

(Peter) 
Okay.

(Lou)  
That's probably, I'm sure that's what she's here to discuss.

(Peter) 
What are you going to tell her?

(Lou)  
I'm going to say back up. I'd like to know more about her eating habits, I'd like to know more about her exercise habits, her family history, if she's had any evaluation for her obesity.

(Peter) 
Does this sound like something you see in the hospital all the time?

(Dr. David Flum)  
It sounds pretty offensive to me. As an employee, she lives for herself. She's not setting up the role model example for patients; she's not being asked to do that in her job. It's completely unacceptable for an employer to put somebody through that kind of...

(Brian Grant)  
But it happens, I mean it happens all the time.

(Peter) Let me give the surgeon the benefit of the doubt perhaps for the first and last time on this broadcast.

[laughing]

(Peter) 
Let's just say that he is concerned about her health. Wouldn't she be better off skinny?

(Dr. William O'Malley) 
No not just being skinny. There's nothing magic about being skinny. I think that being not morbidly obese would make her healthier. We can't make people skinny; that's not our business. I've never told anyone that they should have Bariatric Surgery. I would tell them it's an option; it's probably the only option that will provide them with that long term significant weight loss that they seek, but being skinny is not something that we mention when we see patients because it's not, it's not meaningful.

(Kat)  
You would tell them that that type of surgery is the only option that will provide long-term weight loss?

(William) 
Significant long-term weight loss for the vast majority of morbidly obese patients.

(Dr. Peter Salgo) 
But before we go any further, you used a phrase; term of argument here; morbidly obese. What does that mean?
  
(William) 
It's a degree of obesity in lay terms; typically folks who are typically 100 pounds over an ideal body weight or lean body weight of a person of the same sex and height. Morbid means other illnesses are associated with that degree of obesity.

(Peter) 
Well you'll be pleased to note that her primary care physician actually asks her some questions about her life and about what she wants.

(Lou)  
It's about time.

(Peter) 
Here's what Sophie says. He records this in the chart. She says that she has tried dieting before but it didn't really work and she doesn't exercise because she works at night and during the day she takes care of her kids. She used to smoke and she heard all the admonitions about smoking so she stopped, and lo and behold, she gained weight.

(Lou)  
Yeah.

(Peter) 
I can't stop gaining weight. Does this kind of information help you in helping her?

(Dr. Lou Papa)  
Well it does. I mean if we're assuming that she really had this concerted effort at diet, it'd be nice to get more details on that, but we have what we have and the degree of activity; it is helpful. Yes, quitting smoking, it's not an uncommon thing that people put on weight and she's still healthier quitting smoking.

(Peter) 
Is she doing enough? I mean it sounds like she's tried everything, or should she try harder?

(William) 
As I said before, you know there are, people can lose a lot of weight. I've had patients who've come in after losing, who are several hundred pounds overweight and have lost 100 pounds. It's difficult to maintain that weight loss for most people. Some can do it, but most can't. Lou is right; a person should have demonstrated a commitment to weight loss in the past in a healthy way, not in strange, unusual crazy fad diets, but in good healthy living.

(Melissa)But the patient and her surgery should be satisfied that she's given it a good try.

(William)  
Oh exactly.

(Peter) 
You were in this position in some respects is that right?

(Brian)  
I was. I dieted, I exercised, I did all of it. I yo-yoed back and forth, up and down, different weights. I'd lost 40 or 50 pounds, and gained 40 or 50 pounds. You try different things and it doesn't stay off.

(Dr. Peter Salgo) 
Did you think of yourself as overweight or just somebody whose family is large and so am I?

(Brian)  
I thought of myself as overweight and athletic. 

(Peter) 
Well Sophie doesn't. Sophie does not think of herself as overweight. She talks to a doctor about it. She certainly doesn't think of herself as morbidly obese and she is asked about it. She is not diabetic; she doesn't have high blood pressure. Everyone has been telling her to diet and exercise and that's all she's ever going to need. Is it realistic for people to be on her case to get on that diet and exercise thing or is that just not going to work?

(David)  
Well I think there's a reality here about people who are heavy. You've lived this, but there's a bit of wisdom in the medical literature that 95% of people who lose more than 5% of their body weight will regain that within 5 years and so the real question is can she affect life long behavioral changes that's going to keep this weight loss forever or is she going to need some other help. 

(Peter) 
Well what about diet pills?

(Lou)  
Diet pills are kind of in a worse category in my mind because there's very little data on them. We've had some bad experiences with the diet pills in the past.

(David)  
Any kind of intervention that can achieve more than 5% weight loss improves people's diabetes, improves their hypertension. We know that these things, that if they can affect weight loss can help.

(William) 
I think you're both correct. Weight loss through any means will show an improvement in glucose control and blood pressure control. There's not a lot of magic about surgery in that regard. But also the weight loss results from these medications through these randomized studies for our patient population were really under whelming; that's part of the problem.

(Kat)
Well I have to say...

(Peter) 
Brian how heavy were you when this all started?

(Brian)  
When I had the surgery I was 325, but I...

(Peter) 
325. Had you tried diet pills and other things?

(Brian)  
I never tried diet pills, but I've always done exercising, I've done NutriSystem, I've done Weight Watchers, I've done, you know 4 or 5 different; L.A. Weight Loss.

(Peter) 
Well I'll tell you some more. Sophie is still at work, still wrestling with this and her surgeon boss, co-worker talks to her again and he is worried he says now about her health because she's huffing and puffing around the ward when she walks trying to do her job. He keeps suggesting surgery. Now she's really thinking about it so she goes to her family and says my boss thinks I'm overweight. Do you think I'm that big and her family says no you are not. How important is this?

(Melissa) 
I think it's important when considering surgery that the patient be motivated to seek surgery and it certainly happens that co-workers, friends and families have opinions and before pursuing surgery she needs to be satisfied that non surgical treatments will not be affective for her. She and her doctor need to come to that decision.

(Dr. Peter Salgo) 
Does she, with this profile of height and weight, the body mass index that you calculated even qualify for surgery? Is she someone you'd take and take to the operating room?

(William) 
Well those are 2 different questions. People qualify on the basic, on the very basic level of body mass index. The National Institutes of Health say that people, who are body mass index of greater than 40; that's the definition of morbidly obese, are at the most basic level candidates for consideration for surgical treatment. 35 to 40, if they have a potentially significant and reversible co-morbidity associated with the weight so if a person is looking into surgery, those are usually the criteria, the initial screening criteria. In other words, we're not going to be operating on people, who are 20 or 30 pounds overweight; that wouldn't be appropriate. So it's, that is a baseline screening criteria so I would say she is at the simplest level a candidate for the surgery, but taking her to the operating room; there's a long way to go before and if that would ever happen.

(Peter) 
Well let me play devil's advocate for you for a moment. She's got a body mass index, which just barely tips her into this candidate for surgery class. If you wait very long and her body mass index goes to 50, or even 60, now she's not only a candidate for surgery, she's at extreme risk of dying during that surgery. Where's the breakpoint in there?

(David)  
Well this is a huge controversy in the surgical community and I think really nationwide we have to have a debate about it. There are about 10 to 12 million people who are really eligible for the surgery in America based on their weight and their conditions like diabetes and heart disease. At our institution we tend to favor operating at the extreme end of the weight range; 400, 500 pound patients because we know that that group clearly has all, all the bad effects of obesity; diabetes, hypertension, hearts that don't function well. It's much more controversial when you're talking about treating everybody who's just on the edge of obesity with an operation that costs $25,000 and has real healthy risks and implications.

(Peter) 
Brian do you know your body mass index when you had the surgery?

(Brian Grant)  
I do; it was 42. I also had high blood pressure and sleep apnea.

(Peter) 
Before we go any further though let me just stop and sum up what we've talked about so far because we've covered a lot of ground. Obesity is a major problem in the United States and not everyone can make diet and exercise work. Diet pills don't seem to be the answer. Obese people then are left with the medical and social consequences of being fat and a lot of these are real. Well let me tell you about Sophie because Sophie decides to go see a Bariatric Surgeon. So what questions need to be answered by Sophie before she gets the operation?

(Melissa)
At this point she's probably met the BMI criteria, but she and her doctor need to be satisfied that non-surgical approaches to weight control have not, not proven effective for her. Has she indeed tried dieting? What types of diets or medications has she tried over the years? What has been her weight trajectory over time? In considering that in conjunction with a good understanding of the potential outcomes, risks, and benefits of surgery and when she's satisfied that non surgical approaches have not proven effective and she's willing to accept the risks and likely outcomes of surgery, that she understands, that she can sense that she's opting for surgery and not doing it under duress from family or coworkers.

(Kat)  
Or surgeons.

(Melissa)
Or surgeons.

(David)  
We need to make sure she understands what she's getting herself into.

(Peter) 
What is she getting herself into?

(David)  
It's a huge educational process for patients. First of all we're talking about Bariatric Surgery like its one thing. In fact this is a cluster of operations that have evolved over the last 50 years really.

(Peter) 
Brain what was it like for you when you were in this pre-operative period getting evaluated?

(Brian)  
That part of the program is you have to see a psychologist; you have to see a nutritionist. You have to see the nutritionist twice when I was doing it. Seeing the psychologist they want to make sure that you're not a comfort food eater, you haven't been abused or eating food because of abuse or you're not an alcoholic. I mean there are a lot of different things in your mind that you're going through when you're talking to the psychologist.

(Dr. Peter Salgo) 
How many of these procedures are done? How many people have had some sort of surgery for weight control in this country?

(Dr. David Flum)  
In the last 5 years we've done more Bariatric Surgery in America than we did in the 50 years preceding it. Every year about 150 to 170,000 operations are now performed nationwide and that has just skyrocketed in the last 10 years.

(Peter) 
Well I'll tell you what happens with Sophie. Sophie goes ahead and decides to try surgery and her surgeon and she decided to do something called Gastric Banding. What is it, how does it work, and why does it work?

(David)  
So in an adjustable Banding Procedure, we're putting an inflatable band around the top part of the stomach. That band is connected to tubing which sits underneath the skin and the tubing gets inflated with water and the band shrinks or opens in size. As the size of the band opens and closes with adjustments done in the doctor's office, the size between the top part of the stomach and the bottom part of the stomach changes as well. As that gets smaller and smaller it takes more time for food to go from the top part of the stomach to the bottom part of the stomach. People feel that they have restriction in what they can eat. That restriction is really the goal of an Adjustable Banding Procedure and that restriction is something that we aim for with those adjustments. 
 
(Brian)  
I exercised...

(Peter) 
What operation did you have?

(Brian)  
I had Gastric Bypass.

(Peter) 
You did?

(Brian)  
Yeah.

(David)  
That's one type of operation that's most common in the United States, which is reducing the stomach to an egg size shape and then re-attaching that egg sized stomach to the intestinal track.

(Peter) 
How is your life in terms of your day-to-day existence different than before you had the surgery?

(Brian)  
I eat 5 meals a day, I do, you know, I count my calories; I exercise 2 hours a day. It takes a lot of time.

(Kat)  
Well were you exercising 2 hours a day and eating 5 meals a day prior to your surgery?

(Brian Grant)  
I have tried that, sure.

(Kat)  
No, were you doing that prior, just prior to your surgery?

(Brian)  
Yes just prior to the surgery I was.  I had to change my lifestyle.

(David)  
This is one of the biggest paradoxes, this is the biggest paradox is that afterwards, and the operation's not making you exercise more...

(Brian)  
Absolutely not.

(David)  
But what happens is this is part of a trans-formative event in somebody's life. The operation is part; you're part of a team when you have the operation. He comes to see his doctor, I'm sure you're seeing a nutritionist and social worker as they do in our program and you're part of a team that's affecting massive behavioral change. But the question is could you have done it without the operation?

(Peter) 
Let me ask you a couple of quick questions that this has all brought to my mind. First of all, of everybody that comes to your office for this surgery and gets interviewed and has a psychological profile, perhaps does 6 months of intensive dieting...

(Melissa)
And extensive medical screening.

(Dr. Peter Salgo) 
And extensive medical screening. What percent go to surgery, what percent do you say no you're not an appropriate candidate?

(David)  
Well here's the embarrassing thing; we do not know...

(Peter) 
We don't know?

(Dr. David Flum)  
We don't know which patients should not have Bariatric Surgery. We haven't figured it out yet. I would say that most of your patients, most of my patients who come end up going on to surgery.

(Peter) 
I'll tell you what Sophie did. She had the surgery and she lost 100 pounds in a period of 16 months all right? I think I know the answer to this, but just reiterate this for me. Is that it, is she done? She's all fixed? She doesn't have to do anything else?

(David)  
She's never fixed.

(Peter) 
She's never fixed?

(David)  
The adjustable band is actually an interesting operation in terms of that. You know it takes much longer to lose the same amount of weight with an Adjustable Banding Procedure as it does with the Bypass so I was surprised that she lost so much weight in so little amount of time, but certainly it can happen in a motivated patient. We usually say by, with the Gastric Bypass at about a year and a half out you've lost about as much weight as you're going to lose and that's often about 1/3 of your weight. With a Bypass that makes it take 3 years to get there, is she there forever? Absolutely not. She's at risk of regaining that weight if she doesn't continue to see her doctor and get those adjustments of the band and actively participate in these behavioral changes.

(Brian)  Through exercise.

(Peter) 
How much did you lose?

(Brian)  
I've lost 120 in a year.

(Peter) 
120 in about a year.

(Brian Grant)  
About a year.

(Dr. Peter Salgo) 
So really, I mean you take a look at Sophie's weight loss, your weight loss its tracking and that's about the ball park.

(David)  
That's unusual, that's unusual. Yeah, for Sophie. It's unusual for somebody who's had a Band Procedure to track equally with somebody who's had a Bypass Procedure.

(Peter) 
If you've had the surgery, all the upside, which is the weight loss I expect, makes you feel better, what is the downside? What are the side effects of the surgery that most patients complain about?

(David)  
Well let's start with the Bypass operation. The first is that that's a major operation. Just getting you out of the hospital is the first step and if patients make it out of the hospital we know that their first 90 days can be rough. People estimate that 1, between 1 out of 200 down to 1 out of 50 people die within 30 days of the operation.

(Peter) 
Stop there.

(Dr. William O'Malley) 
Yeah I'd stop there.

(Peter) 
1 out of 50 people; 2%?

(David)  
So I just gave you a range of values, a range of numbers. That includes people who are at high risk like Medicare patients who are disabled and patients who are at very low risk; patients who are like Sophie who are at extremely low risk. And I was specifically talking about the Bypass operation there, not the Banding.

(William) 
No, I understand I think, but all of those things are risks but I think that some of those are overstated. I think most large series don't show even the 0.5 or the 1 in 200 risk that the popular press still puts out.

(Peter) 
What about, we hear about skin changes, hair changes, things like that?

(William) 
If you're talking about complaints, patients aren't complaining about leaks and infections. They're complaining, you asked before about what do they complain about. I'm not going to step on Brian's toes, but what people tell us about are...

(Brian)  
Excess skin.

(William) 
Are things like excess skin, hair loss during the weight loss period.

(Brian)  
True. I already lost mine.

[laughing]

(William) Nausea immediately after surgery.

(Peter) 
That wasn't an issue. Let's stop for a second shall we and sum up where we are before we go even forward because I can tell you that at this point Sophie's really happy with her surgery. Bariatric Surgery requires changes in your lifestyle and that will include eating habits; you've got to comply with an exercise program, there's a lot going on here, just, not simply just surgery. So I want to go back to Sophie. Sophie is experiencing now some difficulties after her initial rush of enthusiasm. She ends a relationship because she's embarrassed about her body. She was not prepared for what, Brian you alluded to, which was excess skin.

(Brian)  
Sure.

(Dr. Peter Salgo) 
Skin redundancy is what her doctor called it. What's that all about?

(Brian)  
Your stomach may hang over your belt or your chest is sagging or you have excess skin on your legs or your arms.

(Peter) 
This is the skin that used to hold all the fat in?

(Brian)  
That I had before.

(Dr. David Flum)  
Stretched out skin.

(Brian Grant)  
Stretched skin.

(Peter) 
Stretched out skin. Is that a real problem and what do you do?

(David)  
Well I mean this is one of the real problems and we've created an entire cottage industry of plastic surgeons who can now work on this redundant skin and help people through a major remodeling in the same way that patients who've had cancer operations often get reconstructions by plastic surgeons.

(Peter) 
Who pays for the plastic surgery? 

(David)  
That's the unfortunate part. We know this is a side effect of the operation and yet the health care system really hasn't kicked in to address it. It's still considered cosmetic. Medicare for example doesn't; really cover that intervention nor would Medicaid.

(Lou)  
I've had a patient with several tens of thousands of dollars worth of plastic surgery on their credit cards.
 
(Peter) 
Brian what was your experience? Did you have excess skin?
 
(Brian)  
I don't have that much excess skin. I haven't had my annual checkup yet, the 1 year checkup to go through the plastic surgery process.

(Peter) 
So your experience then has been pretty good after your operation?

(Brian)  
I've had a great experience, yeah.

(Dr. Peter Salgo) 
Well Sophie is complaining of stress with the changes she's seeing in her body and her lifestyle. She had to re-learn how to eat; she didn't like that. she had to re-learn the quantity that she could eat; she had to re-learn everything. She complains about, and here's a quote from her; the stress is causing me to eat more and she's gaining weight.

(Dr. William O'Malley) 
See I think she, it sounds like she wasn't properly counseled before surgery.

(Lou)  
It sounds like she wasn't ready. I mean she said right from the beginning she didn't see herself as overweight. Somebody else told her she needed to have the surgery and she was on the fence the whole time.

(Kat)  
I think a lot of the message that you hear in the media from people who are on programs or you know, sound bytes on news programs that, you know this is a good option, especially when diets and exercise have failed and you never, or you see the people in People Magazine but you don't see the stories of people who have gone through the procedure and gained the weight back or gained at least a significant amount of weight back. I know, you know, a handful of people who have had the procedure; 3 of them have gained significant amounts of weight to the point now where they are obese again. Those are the stories that you don't hear in the media.

(William) 
But that's what each patient should hear well before they make the decision.

(Lou)  
Right, that's right.

(William) 
That's part of Informed Consent, I mean all of that, the differences in her eating pattern, the impact on her psychological well being after surgery, how things might change, the possibility for weight gain; we tell on the first 5 minutes when we first meet people is that 1 in 5 people, especially for the Bypass, even for the Bypass where you are bypassing the intestine will have significant weight re-gain.

(Kat Carney)  
I think that that's a message that needs to go along with any discussion of Bariatric Surgery.  But it's one that you very rarely hear.

(William) 
Well you don't see it in the newspapers and the news.

(Kat)  
And that's where a lot of consumers are getting their message.

(Dr. Lou Papa)  
I get concerned that she didn't have the same screening process that a patient of mine would if they go to Bill. My patients very often if they go to Bill will say, I'm kind of surprised how he was just very, you know, very nonchalant about what the risks were and this is not, he didn't sell it. I think that's an important point is to really lie out in an unemotional way what the real risks are. It doesn't sound like she ever really was on board.

(Melissa) 
Or I think sometimes patients aren't always receptive to the information so a lot of information comes prior to surgery. One part of that is that there will be major changes in eating and that there are certain patients or habits that can lead to re-gain.

(David)  
There is a silver lining here. She had an Adjustable Band placed and unlike the Gastric Bypass, which is really an irreversible operation, but with the band, that is a removable device and it is completely reversible. It requires an operation to reverse it.

(William) 
The band can be taken out is what you're saying and then say you know what, you gave it a try and it didn't work for you, but that's, to me sort of the utter failure.

(Peter) 
Well Sophie decided she wanted to give it another go, but not with the band so Sophie decided, I guess after talking with her surgeon to convert from the band to Gastric Bypass Surgery.

(David)  
Before she has that though, what we really need to figure out is what does Sophie want?

(Lou)  
Right.

(Brian)
I mean where is her mind?

(Dr. David Flum)  
Sophie's is going to drive all of the post-operative behavioral Therapy. We talk like this is some kind of magical thing. This is a technical procedure. Yes we can do a Bypass on her, but the same issues about control of what she's taking in and what she wants in terms of behavioral modifications will come to bear and if those things have not changed because it's coming from her, then this too will be a failure.

(Peter) 
I can tell you what they did do with Sophie was to go ahead and do Gastric Bypass Surgery. What can she expect now?

(William) 
I would expect that the data would say that she's not going to achieve the original weight loss that she had before and maintain it long term.

(Lou)  
Kat and I are thinking the same thing. This is a lady who originally was told to lose weight because somebody else told her to and she didn't see herself as fat. I'm hoping at some point somebody has sat down with her and said why do you want the surgery?

(Peter) 
Are the nutritional requirements different for the band versus the Gastric Bypass? Does she have to eat differently, supplement differently, vitamins, anything else?

(David)  
Mostly, there are differences and we can highlight them. I mean but remember that most people have a Bypass operation are taking something like 2/3 less of the calories that they used to take in so if they weren't taking enough calcium before, and most people don't take enough calcium in, they'll need to supplement that. If they weren't taking enough vitamins in before, they'll need to supplement that.

(Peter) 
Well if she wasn't psychologically ready to get on the program with the Banding Operation; is she likely to be happy with the Bypass Operation?

(David)  
I don't think so.

(Melissa Kalarchian) 
Well she's opted for an operation that will combine restriction of her intake with a degree of mal-absorption so that may work to her advantage in weight loss, but with either operation, be it at 18 months or with the band; 2 years or 3 years, she'll enter a period of kind of either weight re-gain or stabilization and that's where there's a big role for behavior.

(Peter) 
Brian, were you worried about the operation when you had it?

(Brian)  
I was; I was pretty comfortable with my surgeon. I, I was not worried about the operation at all.

(Dr. Peter Salgo) 
You were aware of all the potential risks though?

(Brian)  
Yep. I did a lot of research, my mom sent me a lot of emails and cut a lot of articles out so you know I did a ton of research on it and I was pretty comfortable.

(Peter) 
Let's pause just for a minute here and sum up a little bit of what we've been talking about. Bariatric Surgery is an effective weight loss procedure but there are consequences, there are risks you need to be aware. You need to have good communication with your doctor so that you're not surprised with any of the results and you've got to get on with the program. Let me tell you a little bit about Sophie now because she's had her surgery. She's down to 132 pounds. She's had skin reduction surgery and while she's experiencing some vitamin deficiency, according to her doctor she's repleting the vitamins along with a plan that her doctor has suggested. Brian, at the end of the day how're you doing? This is not the end of the day is it?

[laughing]

(Peter) This is not the end of the day, is it?

(Brian)  
It's not the end of the day. It will never be the end of the day. I'm doing good. I take calcium pills, I take multivitamins. Bicycle riding is my new thing. I did a couple years prior to getting surgery, but now I'm racing and it makes me feel good.

(Peter) 
Thank you so much for being here. This isn't easy to discuss in public and I really admire you for coming by.

(Brian Grant)  
Thanks.

(Peter) 
Guys, a great discussion. Thank you all. Before we leave today I want to sum up some of the key things that we need to remember. Obesity is a major problem in the United States and not everyone can make diet and exercise work. Diet pills are not the answer. Obese people are left with medical and social consequences of being fat. Bariatric Surgery requires changes in your lifestyle. These include eating habits and complying with an exercise program. Bariatric Surgery is an effective weight loss procedure, but there are consequences and there are risks that you need to be aware of. You need to have good communication with your doctor so you're not surprised with any of the results that you may have. And of course our final message is this; taking charge of your health means being informed and having quality communication with your doctor. I'm Dr. Peter Salgo and I'll see you next time for another Second Opinion.


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