The global rise in obesity has led to a corresponding increase in the number of weight loss surgeries performed. Bariatric surgery is often considered the most effective intervention for obesity, offering the potential for significant weight loss and improvement in related health conditions. However, it is essential to carefully consider both the benefits and risks associated with these procedures.
Understanding Bariatric Surgery
Bariatric surgery, also known as weight loss surgery, encompasses a variety of procedures designed to help individuals with severe obesity achieve and maintain a healthier weight. These surgeries work by altering the digestive system to limit food intake, reduce nutrient absorption, or both. The primary mechanisms involve creating a restrictive or malabsorptive bowel anatomy.
Types of Bariatric Procedures
Several types of bariatric surgeries are currently performed, each with its own advantages and disadvantages:
Laparoscopic Adjustable Gastric Band (LAGB): This restrictive procedure involves placing a band around the upper part of the stomach, creating a smaller pouch that limits the amount of food that can be consumed. The band can be adjusted by inflating a subcutaneous port with saline. It is considered the least invasive and most commonly performed bariatric operation worldwide.
Laparoscopic Vertical Sleeve Gastrectomy (VSG): This primarily restrictive operation involves removing approximately 80% of the stomach, leaving a long, tube-like pouch. This smaller stomach restricts food intake. It has gained popularity in recent years as a stand-alone procedure for weight loss.
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Laparoscopic Roux-en-Y Gastric Bypass (RYGB): This procedure combines both restrictive and selective malabsorptive mechanisms. A small gastric pouch is created and connected directly to the small intestine, bypassing a significant portion of the stomach and duodenum. This limits food intake, reduces nutrient absorption, and can lead to dumping syndrome, discouraging the consumption of simple sugars. It is considered by many to be the gold standard bariatric operation.
Laparoscopic Biliopancreatic Diversion with or without a Duodenal Switch (BPD/DS): This primarily malabsorptive operation involves a sleeve gastrectomy combined with bypassing a large portion of the small intestine. This procedure is technically challenging and typically reserved for severely obese patients.
Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S): During 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.
Benefits of Bariatric Surgery
Bariatric surgery offers numerous potential benefits for individuals struggling with severe obesity and related health problems.
Significant and Sustained Weight Loss
Bariatric surgery is considered the most effective treatment for obesity in terms of maintenance of long-term weight loss. Weight loss averages 65% for most patients undergoing Roux-en-Y gastric bypass, with over 85% of patients losing and maintaining 50% of their initial excess weight loss. The significant and rapid weight loss after surgery can lead to changes in hormones and lead to even more weight loss.
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Improvement or Resolution of Obesity-Related Comorbidities
Weight loss surgery can improve or eliminate most medical problems associated with obesity. Many people with diabetes see their blood sugar levels normalize within days of the operation. Bariatric surgery can also lead to significant improvements in conditions such as:
- Type 2 diabetes
- Hypertension
- Dyslipidemia
- Sleep apnea
- Heart disease
- Arthritis
- Acid reflux
Data presented at the 2018 American Society for Metabolic Surgery meeting provided further evidence that people who undergo weight loss surgery experience a significant decrease in their risk for coronary artery disease. Surgery for weight loss lowers the risk of death related to many diseases including heart disease (40% lower), diabetes (92% lower), and cancer (60% lower) are also significantly reduced.
Enhanced Quality of Life
Weight loss surgery can have a profound impact on an individual's quality of life. As patients lose weight, they often experience:
- Increased energy levels
- Improved mobility
- Reduced pain
- Increased self-esteem
- Better work and social interactions
- Improved sexuality
Increased Fertility in Women
Women may become more fertile in the months following surgery.
Risks and Complications of Bariatric Surgery
While bariatric surgery offers significant benefits, it is essential to be aware of the potential risks and complications associated with these procedures.
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Perioperative Risks
Modern bariatric procedures have strong evidence of efficacy and safety. Current data indicate that the perioperative mortality rates range from 0.03% to 0.2%, which has substantially improved since early 2000s. However, as with any major surgery, there are inherent risks, including:
- Bleeding
- Infection
- Adverse reactions to anesthesia
Specific Postoperative Complications
Different bariatric procedures carry their own specific risks and potential complications:
- Atelectasis: The partial collapse of the lungs. It is very common after surgery, especially in people who are obese. This can lead to problems such as fever, pneumonia, or shortness of breath. Atelectasis can be prevented or alleviated by performing deep-breathing exercises and coughing after surgery.
- Pulmonary Embolism: A blood clot in the lungs. People who are overweight have a higher risk of forming blood clots in the legs, particularly during or soon after surgery.
- Bowel Leakage: Leakage of bowel contents from the new connection between the stomach and the small intestine or between two parts of intestine. A leak from a burst staple line in the sleeve gastrectomy can also occur. Such leaks can cause a high heart rate, pain in the abdomen or back, fever, infection, and even death.
- Difficulty Eating: In gastric bypass surgery, the connection between the new stomach pouch and the intestine is created using a stapling technique. Sometimes, this scar can tighten around the connection and cause it to narrow to a point where food cannot pass through. In people who have had a sleeve gastrectomy, the banana-shaped stomach may become too narrow due to scar tissue, leading to difficulty eating or even drinking. In people who have had gastric band surgery, the opening between the upper and lower stomach pouches can also become too narrow.
- Band-Related Complications: On rare occasions after gastric band surgery, the band erodes into the stomach. In rare instances, the gastric band can slip and cause constant regurgitation and heartburn.
- Nutritional Deficiencies: Malabsorptive procedures, such as biliopancreatic diversion, can lead to protein-calorie malnutrition and micronutrient deficiencies. Long-term issues with fat malabsorption, protein-energy malnutrition and micronutrient deficiencies are relatively uncommon and can usually be managed with oral supplementation.
- Symptomatic Cholelithiasis: The development of persistent and well-described unfavorable surgical consequences requiring additional surgery.
- Anastomotic Strictures and Leaks: The development of persistent and well-described unfavorable surgical consequences requiring additional surgery.
- Bowel Obstruction: The development of persistent and well-described unfavorable surgical consequences requiring additional surgery.
- Gastrointestinal Issues: Bleeding, small bowel bacterial overgrowth, variety of upper and lower gastrointestinal symptoms.
- Dumping Syndrome: Limiting patientsâ consumption of triggering foods (e.g. simple sugars).
Long-Term Considerations
Concerns over unknown long-term consequences of some of these operations also persist, particularly because many bariatric surgery patients are young, and consequently have a long life expectancy.
Patient Selection and Preparation
Bariatric surgery isn't for everyone who is severely overweight. You may need to meet certain medical guidelines to qualify for weight-loss surgery. Current guidelines for patient selection for bariatric surgery are based on a National Institutes of Health (NIH) consensus statement from 1991. These criteria include individuals with a body mass index (BMI) greater than 40 kg/m2 or 35 kg/m2 if obesity-related comorbidities exist, who have failed other means of weight loss and are psychologically stable and able to make the diet, exercise and behavioral changes necessary to be maintain long-term success after surgery.
Patients are required to show proof that their attempts at dietary weight loss have been ineffective before surgery will be approved.
You likely will have an extensive screening process to see if you qualify. 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.
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 most successful bariatric surgery patients are those who also demonstrate active lifestyle changes regarding both improved eating patterns and physical activity.
Long-Term Follow-Up
People who undergo bariatric surgery should expect to visit a doctor for regular checkups several times a year for the rest of their lives. You'll also have frequent medical checkups to monitor your health in the first several months after weight-loss surgery.
Bariatric Surgery in Adolescents
Extreme obesity in the adolescent population is increasingly common with similar causation and health risks as adults. Currently, the criteria for bariatric surgery in adolescents are restrictive. There are a number of unique issues present in adolescents that may justify these more conservative guidelines including concerns over nutrition requirements, linear growth, future pregnancies, unique psychology and informed consent/assent.
The Decision-Making Process
The decision to undergo bariatric surgery is a significant one that should be made in consultation with a qualified medical team. It is essential to carefully weigh the potential benefits and risks, consider individual circumstances, and have realistic expectations about the outcomes.
The decision to perform one bariatric procedure over another ultimately depends not only on the surgeon's experience but also on a number of patient-related considerations, including the patient's weight, comorbidities, reliability and compliance with lifestyle modifications and follow-up. Furthermore, it is important to recognize that the decision is often based on the biases and abilities of the surgeon along with patient's preference and acceptance of risks.