Q and A: A conversation with Dr. Mark Vierra

There was a time when Dr. Mark Vierra believed that anyone who would intentionally perform an operation to produce weight loss should be arrested.

Nearly 15 years and some 1,500 bariatric (gastric bypass) surgeries later, he still believes in the importance of undergoing psychological evaluation and support before embarking on this challenging journey toward health and well-being. He also believes in the procedure. For the right candidates.

Q: When did you begin performing bariatric surgery?

A: I started doing bariatric surgery in 1990. I was on the faculty at Stanford until 2001, when my wife told me I needed to be home more, and home was going to be on the Monterey Peninsula. So I came here and brought the program to Community Hospital, where Dr. (Robert) Lurie and I have done a little more than 600 procedures since 2001.

Q: Why do you think the American Society for Bariatric Surgery designated you and the program at Community Hospital a Bariatric Surgery Center of Excellence?

A: As part of the evaluation process, a rigorous evaluation of the hospital, surgical practice, and individual surgeons is carried out. Centers must demonstrate that they have a multidisciplinary program that encompasses all aspects of patient care, including dietary, psychological, and specialty medical care of these patients. Programs must commit to following up with at least 75 percent of their patients for five years or longer, a difficult commitment in the mobile world in which we live. They must commit to sharing outcomes with other centers of excellence around the country, in an attempt to optimize care and learn from shared experiences. Surgical outcomes are scrutinized. And our outcomes are as good as or better than anywhere in the country.

Q: Why has the procedure become so popular?

A: Back in the 1990s, very few doctors were performing bariatric or gastric bypass surgery. It was more common in the Midwest; almost no one was doing it in Northern California. First of all, the surgical procedures developed in the 1960s and '70s often did not turn out well, so weight-loss surgery got a bad name. Second, obesity was not really identified as the serious medical problem that it is today.

Q: How did you become so involved in bariatric surgery?

A: I really got interested in bariatric surgery through the back door. I already had a particular interest in taking care of diffi cult gastrointestinal problems, among them large cancer operations that caused gastrointestinal problems and patients who experienced problems after undergoing a bypass of the small intestine. I realized the signifi cance of the problem after I reversed a bypass in a 150-pound man who weighed 400 pounds a year later.

Q: Are bariatric surgery patients looking to achieve a better quality of life through ideal weight?

A: When I look at their lives and hear their extraordinary stories, I realize that, for them, "ideal weight" isn't right in the center of the insurance index for weight; in fact, they'd feel very uncomfortable at that weight. If they could be free of 100 pounds, they might reach some normalcy where life doesn't have to become a burden. It's just too badwe have to resort to surgery. There really ought to be a more eloquent way than surgery to bring down weight. I'm so embarrassed the medical field hasn't come up with another way.

Q: What is the profile of an appropriate candidate for bariatric surgery?

A: For the most part, we decide about the appropriateness of the surgery based on guidelines established by the National Institutes of Health. Of course, we run into the limitations of any broad guide when dealing with individuals. Still, if an overweight person suffers from sleep apnea, joint trouble, diabetes, hypertension, and/or a body mass index (BMI) of 35 or more, he or she can consider bypass surgery.

At a BMI of 40 or more, the surgery is often warranted with or without the other disease states because the patient's quality of life is so impacted by living through each day with 100 or more extra pounds. Not everyone with a BMI of 40 or more should have the surgery, and sometimes those with a lower BMI should consider it. We focus on each individual patient; we definitely would recommend it for some and not for others.

Q: What have you learned from performing bariatric surgery?

A: The people I have learned the most from are those I didn't think should have the surgery for one reason or another but I operated on them anyway because it was what they wanted. One patient I considered a bad candidate had a really poor diet and diabetes complications that were out of control. I did the procedure with great misgivings, convinced her health wasn't going to get better. But three weeks later, her diabetes was gone. She has since had a healthy pregnancy, has a new baby, and still has no diabetes.

After doing the procedure for another young woman, a diabetic, I wrote a note to the internist that said, "We will all suffer more for having done this." The note she sent me a year later said, "Now people treat me like I'm more worthy." Five years later, she remains free from diabetes. I never use the word "cure," because the diabetes will return if they gain back the weight. But I have learned to have faith in the patient.

Q: Did you have stereotypes about obesity before you got into this field?

A: I think everybody has stereotypes. I haven't thought about it consciously, but I'm sure I did. The magical thing that happens when you know somebody who has gone through bariatric surgery is that you get to see how your own behavior changes when you see them lose weight and you recognize that you are treating them differently, or have different expectations of them. It's a humbling experience and a valuable education.

Q: A lot of people have lost weight successfully without bariatric surgery. Some would argue that maybe these people who have the surgery just aren't trying hard enough.

A: Imagine if you had epilepsy and people said, "You're just not praying enough." It's a misconception that people living with obesity are not trying hard enough. They have tried and tried and tried. Some people simply cannot get their weight under control on their own or without surgery. In fact, not many people lose a lot of weight without surgery and keep it off.

Q: After bariatric surgery, patients must follow a restricted diet. Why, when a patient didn't have the willpower or discipline to restrict food intake before the surgery, will he or she be willing or able to do so after the surgery?

A: Willpower is an interesting idea. With bariatric surgery, many people are convinced it will be like I've put a cast on them, and they will have an itch they cannot reach. That's not how it works. For most patients, that itch - the food craving - is just markedly diminished.

One possible explanation for this phenomenon is that the hormone grehlin, which makes you hungry and tends to go up as you lose weight, actually plummets after bypass surgery and doesn't go back up. There's no guarantee a patient will eat less, and 10 percent to 15 percent of patients will lose only a disappointing amount of their weight, or gain much of their weight back. But it does make it easier to eat less and, often, to eat better.

Q: Why not just tell the patients to pretend they've had the surgery and eat less?

A: Perhaps hypnotize them to believe they've had bypass surgery? Society has tried hypnosis. We've tried psychology. We've pummeled people with diets. We've used drugs. Obesity is not the same for everybody, and bariatric surgery doesn't work the same for everybody. The surgery is simply a blunt tool that helps set the right patient on the right path. It doesn't cause the weight loss, it facilitates it. We are seeing many people achieve success with it.

Q: How does someone begin the journey toward weight loss through bariatric surgery?

A: Prospective patients must be referred to us by their primary care doctor. We want to make sure, before they go on a 3,000-mile trip, that a good mechanic has gone over their parts and has confidence they can make the journey.

Next, we offer a two-hour lecture once a month that enables the prospective patient to hear about the science behind what controls weight. We encourage family members to come as well; it's very interesting. The second half is about the weight-loss surgery. This lecture is free and is a very good talk for anyone evaluating their options.

The lecture is on the third Wednesday of every month from 7 p.m. to 9 p.m. in the main conference rooms at the hospital. I work really hard to bring in a lot of data and to go over our conceptions and misconceptions about what controls people's weight.

Finally, if they haven't been scared away, they call our office and schedule an appointment to meet with us.

Q: Can people die from complications of bariatric surgery?

A: Yes. In the best centers in the world, the risk looks like 1 in 200 patients. Sometimes it's higher than that. And, since a lot of these patients are young mothers, it's a real concern. We're often dealing with patients who have serious health issues: diabetes, hypertension, 100 or 200 or even 300 pounds of excess weight, and maybe age is a consideration.

Many surgeons, me among them, are superstitious. Let's just say that so far, we've been able to do a lot better than those (1-in-200) averages.