Bariatric (weight-loss) Surgery

Weight-loss surgery is a safe and effective treatment option for those affected by severe obesity. Severe obesity is defined as having a BMI or 40 or greater, or weighing more than 100 pounds over ideal body weight. In addition, a patient with a BMI of 35 or greater with one or more obesity-related diseases is considered to be a candidate for weight-loss surgery.

There is a great amount of importance and responsibility associated with choosing a weight-loss treatment option. Choosing which type of weight-loss surgery is right for you can be a difficult task. It is our goal to provide you with the education needed for you and your physician to make the appropriate treatment selection. Consult with your physician and insurance provider to see if you are a candidate.

Remember, weight-loss surgery is not the “easy way out.” This treatment option is a tool that patients use to lose weight. Surgery is a resource to help reduce weight.

Behavioral, physical and psychological changes are required for you to maintain a healthy quality of life. Continued positive weight-loss relies upon your desire and dedication to change your lifestyle with a proactive approach.

The most commonly performed weight-loss surgeries include: 

• Roux-en-Y Gastric Bypass
• Laparoscopic Adjustable Gastric Banding
• Biliopancreatic Diversion with Duodenal Switch
• Laparoscopic Sleeve Gastrectomy

Note: It is important to note that there are risks involved with weight-loss surgery, as well as any other surgical procedure. Before making a treatment decision, it is important to discuss these risks with your physician and/or surgeon. The OAC also encourages patients to discuss these risks with their family members.

Throughout this section, you will see terms, such as “Malabsorptive,” “Restrictive,” “Laparoscopic” and “Open” in which you may not be familiar. Prior to reading about the different surgeries, we have provided you with a brief description of some of the most commonly used terms when talking about weight-loss surgery.

Open vs. Laparoscopic Procedures
In each section, you will see the surgeries described as being performed “open” or “laparoscopic.” Although the laparoscopic procedure has increasingly gained in popularity and frequency, open procedures are still used in practice today.

“Open” – The open procedure involves a single incision that opens the abdomen, which provides the surgeon access to the abdominal cavity.

“Laparoscopic” – In laparoscopic surgery, a small video camera is inserted into the abdomen allowing the surgeon to conduct and view the procedure on a video monitor. Both camera and surgical instruments are inserted through small incisions made in the abdominal wall.

Malabsorptive vs. Restrictive
Throughout this section, the surgeries will be described as “malabsorptive,” “restrictive” or a combination of the two. Depending on the type of procedure that is determined to be best for your needs, each requires different lifestyle changes.

“Malabsorptive” – Malabsorptive procedures alter digestion, thus causing the food to be poorly digested and incompletely absorbed.

“Restrictive” – Restrictive procedures decrease food intake by creating a small upper stomach pouch to limit food intake.

In addition to these terms, there may be other words, topics or descriptions that you might not understand. If so, make sure to speak with your physician further to gain a better understanding.

Weight-loss Surgery Procedures

Roux-en-Y Gastric Bypass

The Roux-en-Y gastric bypass operation has been used since the late 1960’s to achieve significant weight-loss in people affected by morbid obesity. The operation leads to weight-loss for two different reasons:

• A small stomach pouch reduces the amount you can eat (restriction) and
• A small amount of intestine is bypassed so you don’t absorb all of the food that you eat (malabsorption)

How is it performed?
A gastric bypass can be done through a single long incision (open) or through a series of small incisions (laparoscopic). Regardless of how you choose to have the operation done, the “inside part” is the same.

The surgery involves three basic steps:

• Creation of a small pouch (Proximal Pouch of Stomach)
• Bypassing part of the small intestine (creating the “Short” Intestinal Roux Limb)
• Attaching the bypassed intestine (Roux Limb) to the pouch

The operation can usually be done in two hours or less, but this will depend on many factors. Most patients will need to stay in the hospital for two to three days after their operation and should be ready to return to full activity within two weeks.

How does it work?
To understand how a gastric bypass leads to weight-loss it is helpful to review what you probably learned in grade school: Human Digestion. When we swallow food, it goes down the esophagus and into the stomach. The stomach is able to hold huge amounts of food (think about a hot dog eating contest). The stomach then churns the food and mixes it with digestive juices to break the solid food down into a liquid form. That liquid food then leaves the stomach and goes into the small intestine where it can be absorbed to help fuel our bodies.

The small gastric pouch created during the gastric bypass limits the amount of food (calories) a person can eat during a meal. The pouch will initially hold a very small amount of food (about half a shot glass full or one table spoon), however, by one year after surgery, a gastric bypass patient will be able to eat a meal equal in size to what a 7 or 8-year-old child could eat. Although the meals after gastric bypass surgery are much, much smaller than they were before surgery, they still give the individual the same “full” or “satisfied” feeling they used to get with a much larger meal.

Until food is broken down into the liquid form, it cannot be absorbed by the small intestine. After a gastric bypass, the food does not turn into liquid until it leaves the “Short Intestinal Roux Limb” (see picture). The “Short Intestinal Roux Limb” therefore does not absorb the food that is eaten which results in less food (calories) being absorbed overall (called malabsorption). This also means vitamins and minerals aren’t as well absorbed so gastric bypass patients must be on vitamin and mineral supplements for the remainder of their life.

The “Short Intestinal Roux Limb” does not handle sugar or starches well so gastric bypass patients must limit their intake of sugary and starchy foods. If they don’t, they may experience something referred to as “The Dumping Syndrome.” Usually 10-15 minutes after eating a sugary or starchy food, the individual who is “dumping” begins to experience many of the following symptoms:

• Sweating
• Flushing skin
• Rapid heart rate
• Dizziness
• Low blood pressure
• Abdominal pain
• Vomiting
• Diarrhea
• Shakiness

Dumping typically lasts 30-45 minutes long and then will go away. This gives the gastric bypass patient plenty of time to reflect on the food choice that they made that led to the dumping. For many people who have had a gastric bypass, dumping or the fear of dumping helps them make better food choices and stay away from foods that have tempted them in the past.

Weight-loss: After a gastric bypass, one can expect to lose around 70 percent of the extra weight they are carrying. This means if someone were 100 pounds overweight, they would be expected to lose 70 pounds after gastric bypass. This weight-loss occurs throughout the first 12-15 months after surgery. Proper follow-up and participation in a program that stresses lifestyle modification (dietary, behavioral and exercise changes) will improve the chance a gastric bypass patient will maximize their weight-loss and maintain it for a lifetime.

As the weight comes off, most will see significant improvement in their health and quality of life. Diabetes, high blood pressure, sleep apnea and reflux disease can virtually disappear with significant weight-loss. Most will find they require fewer and fewer medicines over time.

Complications: The major complications that can occur early on after gastric bypass include bleeding, leakage, infections, bowel blockages, blood clots in the lungs (pulmonary emboli) and death. The chance of dying in the first 30 days after a gastric bypass is around .02-.5 percent.

Long-term complications that can occur after a gastric bypass include strictures, ulcers, hernias, weight regain, vitamin and mineral deficiencies and malnutrition. Most of the long-term problems linked to the gastric bypass operation can be prevented with good follow-up.

Conclusion: Gastric bypass is a time-tested, reliable weight-loss operation that can lead to significant and sustained weight-loss by reducing food intake and food absorption. While there are short and long-term risks associated with the surgery, most of these issues can be prevented through close follow-up. As with any weight-loss operation, the best results are achieved when the surgery is combined with a multi-disciplinary program that focuses on lifestyle and behavioral changes.

Laparoscopic Adjustable Gastric Banding

This operation is a restrictive procedure and involves placing a silastic “belt” around the upper part of the stomach. The “belt” essentially separates the stomach into two parts: a tiny upper pouch and a larger lower pouch.

The band is connected by tubing to a port or reservoir that sits below the skin of the abdominal wall usually around the belly button (the port site varies widely by surgeon). The port cannot be seen (and often cannot be felt) from the outside.

Inside of the “belt” is a balloon that can be filled by placing fluid through the port. As the balloon is filled, it slows the passage of food from the upper pouch into the lower pouch. As the band is progressively filled, patients will feel “full” with smaller amounts of food. You will work with your surgeon to determine the number of band fills or adjustments appropriate for you.

Weight-loss: Weight-loss with an adjustable gastric band is typically slow and steady. Band patients generally lose one to two pounds per week during the first year after band placement. Weight-loss can be seen for two to three years after surgery and most patients will eventually lose 35 to 55 percent of their excess weight.

Band patients often see a significant improvement in their weight-related medical problems. Most patients will see a reduction in their need for medications to treat diabetes, high blood pressure and high cholesterol, and in fact many will come off of their medicines completely.

There are several features that make the adjustable gastric band appealing. There is minimal stress to the body at the time of surgery because the band is almost always done laparoscopically and does not involve cutting the stomach or rerouting the intestines. Most patients can go home the same day or the next morning.

Recovery from surgery is usually quick and most people return to work a week or so after surgery. The risk of death from band surgery is equal to or less than 0.1 percent within 30 days after surgery, although many centers report even lower rates. The adjustable gastric band can be easily removed, if necessary.

The adjustability of the band makes it unique among weight-loss operations. This feature allows the possibility of making band adjustments based on the individual weight-loss goals and needs of the patient. The stomach and intestines aren’t bypassed, so vitamin, mineral and nutrition problems after banding are unusual, but still possible. Many programs still recommend vitamin supplementation after banding.

Complications: Patients contemplating adjustable gastric banding must be comfortable with the thought of having a medical device in them for life. Although the band has an excellent safety profile, there are complications that can occur with any weight-loss operation, and the band is no different. It is important for patients to have routine follow up with their doctors for adjustments and monitoring.

The average percent of excess weight-loss is significantly less in most studies with the laparoscopic adjustable gastric band than after gastric bypass. About 10 percent of patients will require a second operation to address a problem with their band.

Although no problems have been reported to date, it is unknown what effect this medical device will have in the body in 20 to 30 years. It is also unclear at this point what the long-term (more than 10 years) weight-loss results with this operation will be, although the early data is promising.

After banding, patients need to be available for regular follow-up, especially in the first year after surgery when the band is being adjusted. If you live several hours from your surgery center, this can be difficult. Adjustments are made by filling the band through the port with fluid through a needle.

Band patients do not suffer adverse effects from eating sugars (dumping syndrome) so they need to be more disciplined in their food choices. Things like sodas, ice cream, cakes and cookies slide through the band easily, but obviously these choices will not lead to the desired goal of significant weight-loss.

Conclusion: Adjustable gastric banding is a safe, effective weight-loss operation that can lead to meaningful, sustained weight-loss. No matter what weight-loss operation is chosen, individuals need to change their lifestyle and learn to work with the surgery in order to be successful.

Biliopancreatic Diversion with Duodenal Switch

What is a Biliopancreatic Diversion with Duodenal Switch?
The Biliopancreatic Diversion with Duodenal Switch (BPD/DS) is often an open operative procedure, however it may be performed laparoscopically.

How is the Biliopancreatic Diversion with Duodenal Switch performed?
BPD/DS is based on a smaller stomach and combines a lower restriction and a high level of malabsorption. The outer margin of the stomach is removed (approximately two thirds) and the intestines are then rearranged so that the area where the food mixes with the digestive juices is short.

A portion of the stomach is then left with the pylorus still attached and the duodenum beginning at its end. The duodenum is then divided, allowing for the pancreatic and bile drainage to be bypassed. It is a pyloric saving procedure, which eliminates the “dumping syndrome” that is inherent to gastric bypass.

Weight-loss: The procedure allows for increased malabsorption, resulting in increased weight-loss. Foods high in fat content are not easily absorbed and will be eliminated along with the usually high calories associated with the high fat.

In all weight-loss surgery options, carbohydrates and sugars are absorbed, so eating foods high in sugar (and calories) will still cause unwanted weight gain or inability to lose weight.

Complications: The BPD/DS requires a much longer recovery period (usually six to eight weeks), causes the greatest risk for infection (due to the size of the incision, increased operative time and exposure of the digestive organs) and usually carries a 25 percent chance for development of incisional hernia post-operatively (due again to the length of the incision). The BPD/DS also carries the highest risk of nutritional deficiencies post-operatively due to malabsorption.

B-12 deficiencies are not created by the Duodenal Switch. Of course, all patients are monitored for iron and B-12 as well as other fat soluble vitamin deficiencies. BPD/DS patients are specifically monitored for fat soluble (A,D,E,K) deficiencies.

Patients who undergo BPD/DS are able to enjoy nutritional foods and eat more normally without the restriction of a small pouch (one to two ounces) as in a gastric bypass.

The BPD/DS is a more invasive operation. According to a recent analysis, BPD/DS carries a mortality rate of 1.1 percent within 30 days after surgery.

Conclusion: Patients are always encouraged to maintain the commitment to lifestyle and food changes associated with weight-loss. BPD/DS patients are asked to first increase protein intake; then vegetables; and lastly, if able at all, breads, pastas or rice in very limited amounts.

Laparoscopic Sleeve Gastrectomy

What is a Laparoscopic Sleeve Gastrectomy?
The laparoscopic sleeve gastrectomy (LSG) originated as the restrictive part of the duodenal switch operation. In the last several years, though, it has been used by some surgeons as a staging procedure prior to a gastric bypass or duodenal switch in very high risk patients. It has also been used as a primary, stand-alone procedure by some surgeons.

How is the Sleeve Gastrectomy performed?
The majority of sleeve gastrectomies performed today are completed laparoscopically. During the sleeve gastrectomy, about 75 percent of the stomach is removed leaving a narrow gastric tube or “sleeve.” No intestines are removed or bypassed during the sleeve gastrectomy. This procedure takes one to two hours to complete. When compared to the gastric bypass, the sleeve can offer a shorter operative time that can be an advantage for patients with severe heart or lung disease.

Weight-loss: LSG is a restrictive procedure. It greatly reduces the size of the stomach and limits the amount of food that can be eaten at one time. It does not cause decreased absorption of nutrients or bypass the intestines. After this surgery, patients feel full after eating very small amounts of food. LSG may also cause a decrease in appetite.

In addition to reducing the size of the stomach, the procedure reduces the amount of the “hunger hormone,” ghrelin, produced by the stomach. The duration of this effect is not clear yet, but most patients have significantly decreased hunger after the operation.

Complications: LSG has been used successfully for many different types of bariatric patients. Since it is a relatively new procedure, there is no data regarding weight-loss or weight regain beyond three years. The risk of death from LSG is 0.2 percent within 30 days after surgery.

The risk of major post-operative complications after LSG is 5-10 percent, which is less than the risk associated with gastric bypass or malabsorptive procedures such as duodenal switch. This is primarily because the small intestine is not divided and reconnected during LSG as compared to the bypass procedures. This lower risk and shorter operative time is the main reason for use as a staging procedure for high-risk patients.

Complications that can occur after LSG include: a leak from the sleeve can result in an infection or abscess, deep venous thrombosis or pulmonary embolism, narrowing of the sleeve (stricture) requiring endoscopic dilation and bleeding. Major complications requiring re-operation are uncommon after sleeve gastrectomy and occur in less than 5 percent of patients.

Conclusion: Several studies have documented excellent weight-loss up to three years after LSG. In higher BMI patients who undergo LSG as a first-stage procedure, the average patient will lose 40 – 50 percent of their excess weight in the first two years after the procedure. This typically equates to about 125 pounds of weight-loss for patients with a BMI greater than 60.

Patients with lower BMIs who undergo LSG will lose a larger proportion of their excess weight (60 – 80 percent) within three years of the surgery. More than 75 percent of patients will have significant improvement or resolution of major obesity-related co-morbidities such as diabetes, hypertension, sleep apnea and hyperlipidemia following sleeve gastrectomy.

Gaining Access to Treatment

Note: Individuals affected by morbid obesity rely on their insurance provider to assist them in the process of seeking access to safe and effective medical treatment. Many times they experience difficulty when working with their insurance providers, such as repeated denials of claims. In addition, the process often times seems complicated, and physically and emotionally draining. For more information on working with your insurance provider, please visit the OAC Web site and view the OAC’s Insurance Guide, titled Working with Your Insurance Provider: A Guide to Seeking Weight-loss Surgery.