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You
may be a candidate for surgery if you are an adult with:
- A body mass
index (BMI) of 40 or more (about 100 pounds overweight for men and 80
pounds for women) or
a BMI between 35 and 39.9 and a serious
obesity-related health problem
such as type 2 diabetes, coronary heart disease, or severe sleep apnea
(when breathing stops for short periods during sleep).
- Acceptable
operative risks.
- An ability to
participate in treatment and long-term follow-up.
- An understanding
of the operation and the lifestyle changes you will need to make.
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The Normal Digestive Process
How does surgery promote weight loss?
What are the surgical options?
Adjustable Gastric Band
Roux-en-Y Gastric Bypass
Biliopancreatic Bypass With a Duodenal
Switch
Vertical Sleeve Gastrectomy
What
are the complications of these operations?
Open and Laparoscopic Bariatric
Surgery
Bariatric Surgery for Adolescents
Medical Costs
Is surgery for you?
Research
Additional Reading
Additional Resource
Severe obesity is a
chronic condition that is difficult to treat through diet and exercise
alone. Bariatric surgery is an option for people who are severely obese
and cannot lose weight by traditional means or who suffer from serious
obesity-related health problems. The operation promotes weight loss and
reduces the risk of type 2 diabetes by restricting food intake and, in
some operations, interrupting the digestive process to prevent the
absorption of some calories and nutrients. Recent studies suggest that
bariatric surgery may even have a favorable impact on mortality (death)
rates in severely obese patients. The best results are achieved when
bariatric surgery is followed with healthy eating behaviors and regular
physical activity.
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The
Normal Digestive Process
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Normally, as food
moves along the digestive tract, digestive juices and enzymes digest
and absorb calories and nutrients. After we chew and swallow our food,
it moves down the esophagus to the stomach, where a strong acid
continues the digestive process. The stomach can hold about 3 pints of
food at one time. When the stomach contents move to the duodenum, the
first segment of the small intestine, bile and pancreatic juice speed
up digestion. Most of the iron and calcium in the food we eat is
absorbed in the duodenum. The jejunum and ileum, the remaining two
segments of the nearly 20 feet of small intestine, complete the
absorption of almost all calories and nutrients. The food particles
that cannot be digested in the small intestine are stored in the large
intestine until eliminated.
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How
does surgery promote weight loss?
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Bariatric surgery
produces weight loss by restricting
food intake and, in some cases, interfering with nutrition through
malabsorption. Patients who undergo bariatric surgery must also commit
to a lifetime of healthy eating and regular physical activity. These
healthy habits help ensure that the weight loss from surgery is
successfully maintained.
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What
are the surgical options?
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There are four
types of operations that are commonly offered in the United States:
adjustable gastric band (AGB), Roux-en-Y gastric bypass (RYGB),
biliopancreatic diversion with a duodenal switch (BPD-DS), and vertical
sleeve gastrectomy (VSG). Each has its own benefits and risks. To
select the option that is best for you, you and your physician will
consider that operation’s benefits and risks along with many
other factors, including BMI, eating behaviors, obesity-related health
conditions, and previous operations.
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Adjustable
Gastric Band
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AGB works primarily
by decreasing food intake. Food intake is limited by placing a small
bracelet-like band around the top of the stomach to produce a small
pouch about the size of a thumb. The outlet size is controlled by a
circular balloon inside the band that can be inflated or deflated with
saline solution to meet the needs of the patient.
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Roux-en-Y
Gastric Bypass
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RYGB works by
restricting food intake and
by decreasing the absorption of food. Food
intake is limited by a small pouch that is similar in size to the
adjustable gastric band. In addition, absorption of food in the
digestive tract is reduced by excluding most of the stomach, duodenum,
and upper intestine from contact with food by routing food directly
from the pouch into the small intestine.
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Biliopancreatic
Diversion With a Duodenal Switch
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BPD-DS, usually
referred to as a “duodenal switch,” is a complex
bariatric operation that principally includes 1) removing a large
portion of the stomach to promote smaller meal sizes, 2) re-routing of
food away from much of the small intestine to partially prevent
absorption of food, and 3) re-routing of bile and other digestive
juices which impair digestion.
In removing a large
portion of the stomach, a more tubular “gastric
sleeve” (also known as a vertical sleeve gastrectomy, or VSG)
is created.
The smaller stomach
sleeve remains connected to a very short segment of the duodenum, which
is then directly connected to a lower part of the small intestine. This
operation leaves a small portion of the duodenum available for food and
the absorption of some vitamins and minerals.
However, food that
is eaten by the patient bypasses the majority of the duodenum. The
distance between the stomach and colon is made much shorter after this
operation, thus promoting malabsorption. BPD-DS produces significant
weight loss. However, there is greater risk of long-term complications
because of decreased absorption of food,
vitamins, and minerals.
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Vertical
Sleeve Gastrectomy
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VSG historically had been
performed only
as the first stage of BPD-DS
(see above) in patients who may be at high risk for complications from
more extensive types of surgery. These patients’ high risk
levels are due to body weight or medical conditions. However, more
recent information indicates that some patients who undergo a VSG can
actually lose significant weight with VSG alone and avoid a second
procedure. It is not yet known how many patients who undergo VSG alone
will need a second stage procedure. A VSG operation restricts food
intake and does not lead to decreased absorption of food. However, most
of the stomach is removed, which may decrease production of a hormone
called ghrelin. A decreased amount of ghrelin may reduce hunger more
than other purely restrictive operations, such as gastric band.
Figure
1
Diagram of Surgical Options. Image credit: Walter Pories, M.D. FACS.
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What
are the complications of these operations?
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Early complications
of these operations can include bleeding, infection, leaks from the
site where the intestines are sewn together, and blood clots in the
legs that can progress to the lungs and heart.
Examples of
complications that may occur later include malnutrition, especially in
patients who do not take their prescribed vitamins and minerals. In
some cases, if the malnutrition is not addressed promptly, diseases
such as pellagra, beri beri, and kwashiorkor may occur along with
permanent damage to the nervous system. Other late complications
include strictures (narrowing of the sites where the intestine is
joined) and hernias.
Two kinds of
hernias may occur after a patient has bariatric surgery. An incisional
hernia is a weakness that sticks out from the abdominal
wall’s fascia (connective tissue) and may cause a blockage in
the bowel. An internal hernia occurs when the small bowel is displaced
into pockets in the lining of the abdomen. These pockets are created
when the intestines are sewn together. Internal hernias are considered
more dangerous than incisional ones and need prompt attention to avoid
serious complications.
Research indicates
that about 10 percent of patients who undergo bariatric surgery may
have unsatisfactory weight loss or regain much of the weight that they
lost. Some behaviors such as frequent snacking on high-calorie foods or
lack of exercise can contribute to inadequate weight loss. Technical
problems that may occur with the operation, like a stretched pouch or
separated stitches, may also contribute to inadequate weight loss.
Some patients may
also require emotional support to help them through the postoperative
changes in body image and personal relationships.
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Open
and Laparoscopic Bariatric Surgery
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Bariatric surgery
may be performed through “open” approaches, which
make abdominal incisions in the traditional manner, or by laparoscopy.
With the laparoscopic approach, sophisticated instruments are inserted
through 1/2-inch incisions and guided by a small camera that sends
images to a television monitor. Most bariatric surgery today is
performed laparoscopically because it requires a smaller cut, creates
less tissue damage, leads to earlier discharges from the hospital, and
has fewer complications, especially postoperative hernias.
However, not all
patients are suitable for laparoscopy. Patients who are extremely
obese, who have had previous abdominal surgery, or have complicating
medical problems may require the open approach.
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Bariatric
Surgery for Adolescents
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Rates of obesity
among youth are on the rise. Bariatric surgery is sometimes considered
as a treatment option for adolescents who have developed extreme
obesity. Although it is becoming clear that adolescents can lose weight
following bariatric surgery, there are numerous unanswered questions
about the long-term effects of these operations on
adolescents’ developing bodies and minds.
Experts in
pediatric obesity and bariatric surgery recommend that surgical
treatment only be considered when adolescents have tried for at least 6
months to lose weight and have not been successful. Candidates should
be extremely obese (typically with BMI greater than 40), have reached
their adult height (usually 13 or older for girls and 15 or older for
boys), and
have serious weight-related health problems, such as type 2
diabetes, sleep apnea, heart disease, or significant functional or
psychosocial impairment. In addition, potential patients and their
parents should be evaluated to see how emotionally prepared they are
for the operation and the lifestyle changes they will need to make.
Patients should be referred to specialized adolescent bariatric surgery
centers with a team of experts qualified to meet their unique needs.
A growing body of
research suggests that both weight and health of extremely obese youth
can be favorably changed by bariatric surgery. Over the years, gastric
bypass surgery has been the predominant operation used to treat
adolescent extreme obesity. An estimated 2,700 adolescent bariatric
surgeries were performed between 1996 and 2003 (Arch
Pediatr Adolesc
Med.
2007;161:217–221). A review of short-term data from the
national inpatient sample (the largest inpatient database in the United
States) suggests that these operations are at least as safe for
adolescents as adults. As yet, the adjustable gastric band has not been
approved for use in the United States for people younger than age 18,
but favorable weight-loss outcomes following adjustable gastric banding
for adolescents have been reported internationally.
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Medical
Costs
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Bariatric
procedures, on average, cost from $20,000 to $25,000. Medical insurance
coverage varies by state and insurance provider. In 2004, the U.S.
Department of Health and Human Services reduced barriers to obtaining
Medicare coverage for obesity treatments. Bariatric surgery may be
covered if it is medically appropriate and if it is performed to
correct an obesity-related illness. If you are considering bariatric
surgery, contact your regional Medicare or Medicaid office or health
insurance plan to find out if the procedure is covered.
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Is
surgery for you?
Bariatric
surgery may be the next step for people who remain severely obese after
trying nonsurgical approaches, especially if they have an
obesity-related disease.
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Bariatric surgery
may be the next step for people who remain severely obese after trying
nonsurgical approaches, especially if they have an obesity-related
disease. Surgery to produce weight loss is a serious undertaking.
Anyone thinking about undergoing this type of operation should
understand what it involves. Answers to the following questions may
help you decide whether weight-loss surgery is right for you.
Are you:
- Unlikely to lose
weight or keep it off over the long term with nonsurgical measures?
- Well informed
about the surgical procedure and the effects of treatment?
- Determined to
lose weight and improve your health?
- Aware of how
your life may change after the operation (adjustment to the side
effects of the operation, including the need to chew food well and
inability to eat large meals)?
- Aware of the
potential risk for serious complications, dietary restrictions, and
occasional failures?
- Committed to
lifelong healthy eating and physical activity habits, medical
follow-up, and vitamin/mineral supplementation?
Remember:
There are no
guarantees for any method, including surgery, to produce and maintain
weight loss. Success is possible only with maximum cooperation and
commitment to behavioral change and medical follow-up—and
this cooperation and commitment must be carried out for the rest of
your life.
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Research
Success is possible only with
maximum
cooperation and commitment to behavioral change and medical
follow-up—and this cooperation and commitment must be carried
out for the rest of your life.
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In 2003, the
National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK) of the National Institutes of Health (NIH) formed a partnership
with researchers called the Longitudinal Assessment of Bariatric
Surgery, or LABS. LABS researchers are experts in bariatric surgery,
obesity research, internal medicine, behavioral science, and related
fields. Their mission is to plan and conduct studies that will lead to
better understanding of bariatric surgery and its impact on the health
and well-being of patients with extreme obesity. For more information
on LABS, visit
http://www.niddklabs.org.
To help determine
if bariatric surgery is appropriate for adolescents, NIH launched a
prospective study called Teen-LABS in 2007. Over the next 5 years, the
multicenter study will collect data from adolescents who are scheduled
for surgery to evaluate bariatric surgery’s benefits and
risks. Researchers will collect data about obesity-related medical
problems, other health risk factors, and quality of life from the
patients before they undergo surgery and 2 years after surgery.
Researchers will then compare the adolescent outcomes to data collected
from adults. For more information about Teen-LABS, visit
http://www.nih.gov/news/pr/apr2007/niddk-16.htm
and
http://www.cincinnatichildrens.org/teen-LABS.
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Additional
Reading |
Clinical
Guidelines on the Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults.
National Heart, Lung, and Blood Institute, NIH. September 1998.
Available at
http://www.nhlbi.nih.gov.guidelines/obesity/ob_gdlns.pdf.
Dieting
and Gallstones. This fact
sheet explains what gallstones are, how they are formed, and the roles
obesity and rapid weight loss play in the development of gallstones.
Available from WIN.
Gastrointestinal
Surgery for Severe Obesity.
Consensus Statement, NIH Consensus Development Conference, March
25–27, 1991; Public Health Service, National Institutes of
Health, Office of Medical Applications of Research. This publication,
written for health professionals, summarizes the findings of a
conference discussing treatments for severe obesity. Available at
http://consensus.nih.gov/1991/1991GISurgeryObesity084html.htm.
Pharmacological
and Surgical Treatment of Obesity:
Evidence
Report/Technology Assessment: Number 103. Shekelle
PG, Morton SC, Maglione M, et al. Agency for Healthcare Research and
Quality (AHRQ). AHRQ Publication Number 04–E028–1;
2004. Rockville, MD. This report reviews the scientific evidence on
weight-loss drugs and bariatric surgery among children, adolescents,
and adults. Available at
http://www.ahrq.gov/downloads/pub/evidence/pdf/obespharm/obespharm.pdf.
Weight
Loss for Life. This booklet
describes ways to lose weight and encourages healthy eating habits and
regular physical activity. Available from WIN.
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Additional
Resource |
American
Society for Metabolic and Bariatric Surgery
100 SW 75th Street
Suite 201
Gainesville, FL 32607
Phone: (352) 331–4900
Fax: (352) 331–4975
Internet: www.asbs.org
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Weight-control
Information Network
1 WIN Way
Bethesda, MD 20892–3665
Phone: (202) 828–1025
Toll-free number: 1–877–946–4627
Fax: (202) 828–1028
Email: win@info.niddk.nih.gov
Internet: http://www.win.niddk.nih.gov
The Weight-control
Information Network (WIN) is a service
of the National Institute of
Diabetes and Digestive and Kidney Diseases (NIDDK) of the National
Institutes of Health, which is the Federal Government’s lead
agency responsible for biomedical research on nutrition and obesity.
Authorized by Congress (Public Law 103–43), WIN provides the
general public, health professionals, the media, and Congress with
up-to-date, science-based health information on weight control,
obesity, physical activity, and related nutritional issues.
Publications
produced by WIN are reviewed by both NIDDK scientists and outside
experts. This fact sheet was also reviewed by Walter Pories, M.D.,
FACS, Professor of Surgery and Biochemistry, Brody School of Medicine
at East Carolina University; and Thomas Inge, M.D., Ph.D., FACS, FAAP,
Assistant Professor of Surgery and Pediatrics and Surgical Director,
Comprehensive Weight Management Center, Cincinnati Children’s
Hospital Medical Center.
This publication is
not copyrighted. WIN encourages users of this brochure to duplicate and
distribute as many copies as desired.
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U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No.
08–4006
March 2009
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