Obesity is a prevalent and complex disease affecting millions worldwide. Many individuals grapple with this condition, often finding that diet and exercise alone yield limited or unsustainable results. This article aims to provide a thorough understanding of weight loss surgery, also known as metabolic and bariatric surgery, its benefits, different types, and considerations for those contemplating this option.
Introduction: Beyond the Pounds
Weight loss surgery is a significant intervention designed to aid individuals struggling with severe obesity. It's important to note that this surgery is not a cosmetic solution for those seeking to shed a few pounds. Rather, it is a tool to accelerate weight loss for individuals with a body mass index (BMI) greater than 35, particularly when accompanied by serious weight-related health problems such as type 2 diabetes, high blood pressure, or severe sleep apnea. For individuals with a BMI greater than 35, their chances of reaching a normal body weight for a lasting period of time is less than 1%.
How Weight Loss Surgery Works
Bariatric surgery encompasses various procedures that alter the anatomy of the stomach and small intestines. These alterations impact hormonal signals that contribute to weight gain or hinder weight loss, ultimately making it easier to lose weight. Some procedures limit the amount of food the stomach can hold, while others reduce the body's ability to absorb calories and nutrients.
Types of Bariatric Surgery
Each type of bariatric surgery has its own advantages and disadvantages. Here's an overview of some common procedures:
Roux-en-Y Gastric Bypass
This is the most common method of gastric bypass, typically not reversible. The surgeon creates a small pouch at the top of the stomach, separating it from the lower portion with surgical staples, restricting how much the stomach can hold. Then they divide the small intestine and bring the new segment up to connect to the stomach pouch. Food will now flow through the new, smaller stomach and lower segment of your small intestine, bypassing the rest. This restricts how much your stomach can hold and also how much nutrition your small intestine can absorb.
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Sleeve Gastrectomy
In this procedure, about 80% of the stomach is removed, leaving a long, tube-like pouch. This smaller stomach can't hold as much food. Advantages include significant weight loss and no rerouting of the intestines.
Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
This two-part surgery limits how much you can eat and reduces the absorption of nutrients. During the second step, the surgeon closes off the middle section of the intestine and attaches the last part directly to the first part of the small intestine, called the duodenum. This is the duodenal switch. The separated section of the intestine isn't removed from the body. Instead, it's reattached to the end of the intestine, allowing bile and pancreatic digestive juices to flow into this part of the intestine.
Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S)
During the second step of the SADI-S procedure, a section of the small intestine known as the duodenum is closed off just below the new stomach sleeve. This opening below the new stomach is then connected to a part of the lower small intestine called the ileum. The bypass routes food through only about 10 feet of the small intestine, instead of the usual 25.
Stomach Intestinal Pylorus Sparing Surgery (SIPS)
This newer procedure is a modified version of the original duodenal switch, intended to reduce complications. It also goes by the names Loop Duodenal Switch or SADI-s. Like the original, it begins with a sleeve gastrectomy, then divides the first part of the small intestine just after the stomach (the duodenum). This time, the small intestine is reattached as a loop, which requires just one surgical connection (anastomosis) instead of two. It also means that less of the small intestine is bypassed, allowing for a little more absorption of nutrients.
The best type of weight-loss surgery for an individual depends on their specific situation.
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Benefits of Weight Loss Surgery
Weight loss surgery offers a multitude of benefits beyond just shedding pounds. These include:
Improved Quality of Life
Obesity can significantly impair quality of life, leading to physical limitations, bodily pain, and fatigue. Weight loss surgery has been shown to improve psychosocial functioning and overall quality of life. More than 95% of the patients who had bariatric surgery at UCLA reported markedly improved or improved quality of life after surgery in an anonymous survey.
Remission or Improvement of Type 2 Diabetes
Obesity is a major risk factor for developing type 2 diabetes. Bariatric surgery, particularly Roux-en-Y gastric bypass and sleeve gastrectomy, can be highly effective in treating type 2 diabetes. Improvement in metabolic control is often evident within days to weeks following surgery. In a prospective, longitudinal study that included bariatric-specific data from more than 100 participating institutions and 28,616 obese diabetic patients, remission or improvement in diabetes at 12 months was achieved in 83 percent of patients undergoing a Roux-en-Y gastric bypass, 55 percent undergoing sleeve gastrectomy, and 44 percent undergoing an adjustable gastric banding. The American Diabetes Association recommends bariatric surgery be considered for adults with type 2 diabetes who have a BMI greater than 35, in particular if diabetes or associated co-morbidities are difficult to control with lifestyle and pharmacologic therapy.
Resolution or Improvement of Fatty Liver Disease
Nonalcoholic fatty liver disease (NAFLD) is a common chronic liver disease strongly associated with obesity. Bariatric surgery has been shown to slow down or reverse the progression of NASH. Studies have shown more than 80% of resolution of NASH after bariatric surgery.
Normalization of Hypertension and Hyperlipidemia
Overweight and obesity contribute significantly to cases of hypertension and coronary heart disease. Bariatric surgery can lead to normalization of hypertension in a significant percentage of patients and reduce the need for antihypertensive treatment. Large studies show that bariatric surgery leads to resolution of dyslipidemia in about 60% of the patients. Meta analysis showed that bariatric surgery leads to close to 50% reduction of heart attack risk and more than 50% reduction of stroke risk.
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Relief from Joint Pain and Osteoarthritis
Obesity is a major risk factor for osteoarthritis, particularly in weight-bearing joints. Bariatric procedures can predictably provide relief from joint pain. Retrospective studies have revealed that the frequency of back pain was reduced in up to 83% of patients, and lumbar back pain symptoms were reduced in 82-90% patients after 6-22 months.
Reduced Mortality
Large epidemiologic studies have shown that obesity is associated with a higher chance of dying early. Bariatric surgery has been shown by many studies in Europe and North America to reduce the chance of dying in the long term. A retrospective cohort study in Utah with more than 7,000 patients showed a 40% reduction in all-cause mortality with 7 years of follow up. Recently a large study from VA showed more than 50% reduction of mortality with 5-10 years of follow up. A Canadian study showed that bariatric surgery resulted in 89% reduction of mortality.
Resolution or Improvement of Obstructive Sleep Apnea
Obesity is a strong risk factor for obstructive sleep apnea (OSA). Bariatric procedures have been shown to result in a high rate of resolution or improvement in OSA. The study found that resolution or improvement of OSA for happened in 79% of patient who had Roux-en-Y gastric bypass surgery, 77% of patients who had lap band, and 86% of patients who had sleeve gastrectomy.
Reduced Risk of Obesity-Associated Cancer
Obesity confers an increased risk to various malignancies. Bariatric surgery has been shown to reduce the risk of developing new cancers. A retrospective cohort study from Utah found 40% decrease of all cause mortality and 60% decrease of cancer related mortality. A large retrospective study from Canada showed nearly 80% reduction of cancer incidence after bariatric surgery.
Improved Polycystic Ovary Syndrome (PCOS) and Fertility
PCOS is a common endocrine disorder in women, strongly associated with obesity. Bariatric surgery has been shown to restore menstrual cycles, improve excessive hair growth, decrease androgen levels, and increase fertility rates in obese women with PCOS.
What to Expect Before, During, and After Surgery
Preparation
If you qualify for bariatric surgery, your health care team gives you instructions on how to prepare for your specific type of surgery. You may need to have lab tests and exams before surgery. You may have limits on eating and drinking and which medicines you can take. You also may need to prepare by planning for your recovery after surgery.
During Surgery
Bariatric surgery is done in the hospital using general anesthesia. The specifics of your surgery depend on your individual situation, the type of weight-loss surgery you have, and the hospital's or doctor's practices. Some weight-loss surgeries are done with traditional large incisions in your abdomen. Today, most types of bariatric surgery are performed laparoscopically. Surgery usually takes several hours. After surgery, you awaken in a recovery room, where medical staff watches you for any complications.
After Surgery
After weight-loss surgery, you generally won't be allowed to eat for 1 to 2 days so that your stomach and digestive system can heal. Then, you'll follow a specific diet for a few weeks. The diet begins with liquids only, then to pureed and very soft foods, and eventually, to regular foods. You'll also have frequent medical checkups to monitor your health in the first several months after weight-loss surgery. People who undergo bariatric surgery should expect to visit a doctor for regular checkups several times a year for the rest of their lives.
Potential Risks and Complications
While bariatric surgery offers significant benefits, it is essential to acknowledge the potential risks and complications. These can vary depending on the type of surgery and individual factors. It's also possible to not lose enough weight or to regain weight after any type of weight-loss surgery, even if the procedure itself works correctly.
Is Weight Loss Surgery Right for You?
Bariatric surgery isn't for everyone who is severely overweight. You may need to meet certain medical guidelines to qualify for weight-loss surgery. You likely will have an extensive screening process to see if you qualify. You may be a candidate for weight loss surgery if:
- Your BMI is 40 or higher.
- Your BMI is 35 to 39.9, called obesity, and you have a serious weight-related health problem, such as type 2 diabetes, high blood pressure or severe sleep apnea.
- Patients are required to show proof that their attempts at dietary weight loss have been ineffective before surgery will be approved.
Common Myths About Bariatric Surgery
It's important to dispel some common misconceptions surrounding bariatric surgery:
- Myth: Surgery is a last resort.
- Fact: Bariatric surgery is the most effective long-term treatment for class III obesity.
- Myth: Surgery is the "easy way out."
- Fact: Bariatric surgery can be thought of as a tool that allows a healthy diet and lifestyle to lead to sustained weight loss.
The Importance of Lifestyle Changes
Surgery is only a tool to accelerate weight loss. Patients who follow physician-recommended dietary, exercise and lifestyle changes will have the best chance for life-long success. The long-term success of bariatric surgery depends on your ability to make permanent changes in your behavior and lifestyle.
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