David Strand, MD, and the Team Approach to Weight Loss Surgery at Surgical Institute of South DakotaAug 31, 2020 09:58AM ● By MED Magazine
Before he left for military service in Iraq in 2004, bariatric surgery was not a significant focus for general surgeon David Strand, MD. A graduate of Wake Forest University School of Medicine, Dr. Strand has always enjoyed performing a wide variety of surgical procedures. But when he returned from Iraq, he decided to help develop the bariatric program at Surgical Institute of South Dakota in more depth.
"It's one thing when someone comes in with an emergency and you make them better," says Strand. "But I found that I really enjoyed seeing bariatric patients because you can make such a significant and long-term difference in their quality of life."
As BMI rises, so does the strain on the body. Obesity significantly exacerbates conditions like hypertension, sleep apnea, and diabetes. Many of Dr. Strand's bariatric patients are able to reduce or even eliminate their use of medications after treatment.
Bariatric procedures such as gastric bypass, sleeve gastrectomy, gastric bands, and the intragastric balloon now make up about a third of Strand's practice. More than fifteen years of experience in this area have given him a unique perspective on the evolution of medically-assisted weight loss.
"When we first started, it was all about the gastric bypass and everything was done through an open procedure," says Dr. Strand, who now does almost all bariatric procedures laparoscopically. "These laparoscopic patients have smaller incisions, less postoperative discomfort, and lower hernia rates. And they get to go home sooner."
The most common bariatric procedures at SI are sleeve gastrectomy and gastric bypass. During a sleeve gastrectomy, Dr. Strand removes about 80 percent of the stomach, including portions of the stomach involved in hunger signaling. Patients feel less hungry and have far less stomach capacity.
A more technically challenging procedure, gastric bypass involves creating a small pouch that bypasses the stomach and part of the small bowel. Gastric bypass patients face a higher risk for malnutrition without careful monitoring, but they are also typically the heaviest patients with the highest number of comorbidities. Strand says these patients must be followed closely to prevent deficiencies.
Although gastric bypass patients tend to see more dramatic initial weight loss, at five years, the percentage of patients who successfully keep the weight off with either procedure is nearly the same: 60 to 70 percent with gastric bypass and 60 percent with sleeve gastrectomy.
"It's nice to be able to give patients choices," says Dr. Strand. "In people with a BMI less than 40, I think the bypass is overly aggressive. Once the BMI is over 50, gastric bypass may be better than a sleeve. Although, in a person with a very high BMI, it may be easier to do a sleeve than a bypass."
An adjustable gastric band or intragastric balloon, a temporary device that reduces space in the stomach, can be good options for younger, active people with 40 to 80 pounds to lose. Bariatric specialists at SI are also exploring newer techniques such as the modified duodenal switch or a procedure that combines a partial sleeve and a gastric bypass, which may be especially helpful for people with metabolic syndrome.
Just as their range of weight loss procedures has evolved, so has SI's level of support for bariatric patients. In addition to surgeons, the bariatric team now includes a dietician, a psychologist who specializes in weight loss surgery, integrative medicine specialists, and a health coach. Together, the team helps ensure that patients can stick with the lifestyle changes that will help them maintain lifelong weight loss.
"Weight gain is multifactorial, which is why it takes a group to help these patients," says Dr. Strand. "We require the program now because we know that is going to give patient's the best chance to be successful in the long term. It is so great to see patients 10 or 15 years out who have kept the weight off and are enjoying their family and a good quality of life."