For individuals grappling with overweight or obesity, weight loss often emerges as the key to improved health. While bariatric surgery is sometimes perceived as a cosmetic solution, it is, in fact, a potentially lifesaving medical intervention. Obesity is a common disease in the United States and the world. Many patients with obesity have tried to treat this on their own, with diet and exercise. Many have had some success, only to have weight regain. More often, patients have little to no success with diet and exercise alone. This is not a result of lack of willpower or the wrong diet.
Understanding Obesity and Bariatric Surgery
Obesity is an epidemic that leads to other illnesses like diabetes, high blood pressure, arthritis, sleep apnea, limited or non-existent physical activity and more. Obesity is the medical term for excess body fat and is defined as having a body mass index (BMI) greater than 30 kg/m2. According to the Centers for Disease Control and Prevention (CDC), approximately 40.3% of adults in the United States are obese. Obesity is a chronic medical condition that is caused by a variety of factors. There are behavioral, hormonal, genetic and environmental characteristics that play a role in the obesity epidemic. While obesity is more than just calories in and calories out, sugary beverages and processed foods have contributed to the obesity epidemic.
Bariatric surgery, also known as weight loss surgery, changes the shape and function of your digestive system. Weight-loss surgery is only one part of an overall treatment plan. Your treatment will also include nutrition guidelines, exercise and mental health care.
Debunking Misconceptions
"People often feel like it's their fault and they should be able to lose weight on their own. But obesity is not about overeating and lack of self-control," says Dr. Kulmeet Sandhu, a surgeon at Cedars-Sinai. Surgical weight loss can be a lifesaving solution for many overweight Americans. Yet only 1% of people who qualify for bariatric surgery get the procedure, in part because of misconceptions surrounding weight loss surgery.
Many people consider weight loss surgery to be a last resort. Yet, according to a National Institutes of Health (NIH) expert panel, long-term weight loss is nearly impossible without surgery for people who are severely obese.
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Common Myths
- That surgery is a last resort: Bariatric surgery is the most effective long-term treatment for class III obesity.
- That surgery is the “easy way out.” Bariatric surgery can be thought of as a tool that allows a healthy diet and lifestyle to lead to sustained weight loss.
Types of Bariatric Surgery
There are many approaches to weight loss surgery. As bariatric surgeons, we recommend when a patient should seek an alternative treatment. There are different types of bariatric surgery including gastric bypass, gastric sleeve, lap-band or even gastric balloons. The choice depends on the patient’s individual medical case.
In the early days, doctors often performed gastric band surgery, which sections off the stomach with an adjustable band. Today, the most common procedures are sleeve gastrectomy, a procedure that reduces the stomach to roughly the size of a banana, and laparoscopic gastric bypass, a procedure that connects a tiny section of the stomach to a later section of the small intestine so that food bypasses the majority of the stomach and some of the small intestine.
Sleeve Gastrectomy
Vertical sleeve gastrectomy is a procedure in which 85%-90% of the stomach is removed. A sizer, called a bougie, is placed in the mouth and advanced into the stomach. A cutting stapler is then used to staple alongside the sizer so that a uniform amount of stomach or "sleeve" is left behind. The surgery is restrictive, which aids in weight loss. There is also a metabolic component, as ghrelin decreases following sleeve gastrectomy. Ghrelin, a hormone that stimulates appetite, is made by cells in the stomach. When a large portion of the stomach is removed, patients experience appetite suppression. Sleeve gastrectomy is very effective in the treatment of obesity. Patients can expect to lose 60% of their excess body weight, and most of the weight loss occurs within the first year. The gastrectomy simply removes a large portion of your stomach - about 80% - leaving behind a small, tubular portion, like a sleeve. This naturally reduces the amount of food you can consume in one sitting and makes you feel fuller faster. But it also reduces the hunger hormones that are normally produced in your stomach. This helps to stabilize your metabolism, decreasing your appetite and regulating your blood sugar.
Gastric Bypass
Roux-en-Y gastric bypass is a procedure that is both restrictive and malabsorptive. A stapler is used to create a gastric pouch, which is separate from the remainder of the stomach. In this procedure, the intestines are also re-routed. After the intestines are re-routed, they are in the configuration of a “Y,” which is why the procedure is called a Roux-en-Y. Since food is bypassing the larger part of the stomach and being held in a small pouch, there is a component of restriction. Therefore, patients consume less food and fewer calories, which aids in weight loss. Due to the re-routing of the intestines, there is also decreased absorption, which further facilitates weight loss. Patients can expect to lose 70% of their excess body weight after gastric bypass surgery. The gastric bypass is a great option for obese patients with Gastroesophageal Reflux Disease (GERD) since it is an anti-reflux operation.
The gastric bypass is also known as the “Roux-en-Y," which is a French term meaning “in the form of the letter Y.” With this procedure, your small intestine will end up in that form. First, surgeons create a small pouch at the top of your stomach, separating it from the lower portion with surgical staples. Then they divide your 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. Restricting the small intestine makes this method more effective than gastric restriction alone.
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Biliopancreatic Diversion with Duodenal Switch (BPD-DS)
This is the original version of the duodenal switch, an operation that combines a sleeve gastrectomy with an intestinal bypass. (It sometimes goes by a shorter name: Gastric Reduction Duodenal Switch). It’s similar to the Roux-en-Y gastric bypass but more extreme. This operation bypasses most of your small intestine - about 75%. This significantly reduces the hunger hormones produced in your small intestine as well as in your stomach. It also significantly restricts how much nutrition your small intestine can absorb. This is what makes the duodenal switch the most effective surgery for weight loss and for improving metabolic syndromes like diabetes. But it can also make it hard for your body to absorb enough nutrients to stay healthy.
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. Early results are still being studied, but so far it appears promising that this version may eventually replace the original duodenal switch. 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.
Benefits of Bariatric Surgery
For most people, the risks of obesity are much greater than the risks of bariatric surgery. Studies report a nearly 90% reduction in premature death from all causes after surgical weight loss, as well as dramatic drops in deadly diseases such as diabetes, hypertension and heart disease. And while every surgery comes with risks, bariatric procedures are among the safest on the operating table. The mortality rate (0.1%) of bariatric surgery is less than that of commonplace procedures such as gallbladder removals and hip or knee replacements. "Over the past decade, doctors have refined their techniques, and most procedures are performed laparoscopically through tiny incisions," says Dr. Sergey Lyass, a bariatric surgeon at Cedars-Sinai.
Weight loss surgery does not just treat the disease of obesity, but it treats other conditions like diabetes, heart disease, high blood pressure, arthritis, and acid reflux. Bariatric surgery has been proven to improve and, in many instances, reverse obesity-related conditions such as diabetes and obstructive sleep apnea. Many patients have improved energy following weight loss surgery and a new lease on life.
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.
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While losing weight can dramatically enhance your appearance, the real benefits of weight loss surgery are health and longevity. "Nearly 90% of people with sleep apnea end up with complete resolution of their disease after bariatric surgery, and patients with diabetes end up with lower blood sugar and fewer diabetes-related complications than those who don't undergo the procedure," says Dr. Lyass.
Candidacy and Qualification
The major indication that surgery is required, which is also necessary for insurance to cover costs, is when a person’s body mass index (BMI) is too high. The average age is 40 to 45 years old. However, there’s really no specific age requirement to have the surgery.
The general medical guidelines for weight-loss surgery are based on body mass index (BMI). BMI is a formula that uses weight and height to estimate body fat. In some cases, weight-loss surgery may be an option for adolescents. Instead of using these BMI numbers as a guideline for surgery, a surgeon may use growth charts for adolescents. These charts show the standard BMI range for each age.
Bariatric surgery requirements
Bariatric surgery requirements begin with establishing a diagnosis of class III obesity. That means that you either:
- Have a BMI of 40 or higher. The Body Mass Index (BMI) is a way of estimating how much body fat you have based on your height-to-weight ratio. A score of 40 or higher is associated with a high risk of related diseases. It usually equates to about 100 lbs. overweight.
- Have a BMI of at least 35 and at least one related health problem. A BMI of 35 without a related health problem is considered class II obesity.
The criteria are slightly higher for adolescents. An adolescent may be a candidate if they have:
- BMI of at least 40 and an obesity-related medical condition.
- BMI of at least 35 and a severe obesity-related medical condition.
While BMI is easily measured, you may have to take some medical tests to diagnose your obesity-related health conditions.
Pre-Surgical Preparation
Before scheduling your bariatric surgery, your healthcare provider will want to ensure that you’re physically and mentally fit for the surgery. You’ll meet with a team of specialists who will counsel you about the risks and benefits while evaluating your physical and mental health. Members of your team will explain what to expect before and after the procedure. They will evaluate whether you're ready for surgery and help you decide if it's an option for you. You'll have a medical exam to diagnose any unknown obesity-related conditions. Your doctor also will test for problems that could make surgery more complicated.
You may need to pass medical screening tests to make sure the surgery is safe for you. If you use tobacco, drugs or excessive alcohol, you’ll be required to quit before qualifying for surgery. Your healthcare team can help you with this.
Your surgeon may also ask you to follow a pre-bariatric surgery diet for a few weeks to prepare for your operation. This is to reduce the fat inside your abdomen, where the operation will take place, making the operation safer and reducing the risk of complications. Your surgeon will give you specific guidelines to follow. Many bariatric surgeons put their patients on a special pre-operative diet, usually 2 or 3 weeks just before surgery. The reason for the pre-operative diet is to shrink the liver and reduce fat in the abdomen. Some insurance companies require a physician-monitored diet three to six months prior to surgery as part of their coverage requirement.
The entire process typically takes four to six months. Our medical staff actually begins working with the patient to change their habits four to six months before the surgery. If patients don’t follow my instructions before the surgery, we postpone it. Candidates really have to make sure the surgery is what they want and they’re committed.
Comprehensive Evaluation
Weight loss after surgery depends on your ability to change behaviors in eating and exercise. Also, being in good mental health is important for the demands of following your treatment plan.
The team will need to assess:
- Motivation: Are you motivated to embrace lifestyle changes, set goals and educate yourself about healthy nutrition?
- Weight-loss history: What dieting and exercise plans have you used in the past to lose weight? Did you lose weight or regain weight?
- Eating behaviors: Irregular eating behaviors or eating disorders may contribute to obesity. These include binge eating, nighttime eating and unplanned grazing between meals.
- Mood disorders: Depression, anxiety, bipolar disorder or other mood disorders are associated with obesity, and these conditions may make it difficult to manage your weight.
- Alcohol and drug use: Problems with alcohol or drug use, as well as smoking, are associated with poor weight loss and continued substance use problems after surgery.
- Suicide risk: There is an increased risk of suicide among people who have undergone weight-loss surgery.
Developing a Treatment Plan
If your team members recommend bariatric surgery, they will work with you to develop a treatment plan including:
- Nutrition guidelines: The dietitian will help you with nutrition guidelines, vitamin supplements and menu planning.
- Exercise plan: Weight loss.
- Psychotherapy: You may be required to begin talk therapy, drug treatment or other mental health therapy to treat an eating disorder, depression or other mental health condition.
- Smoking cessation:
- Other treatments:
These requirements are intended to help you achieve the best possible weight-loss outcomes after surgery. Also, your ability to follow through on these plans will show your team how motivated you are to follow guidelines after surgery.
Surgical Procedure and Postoperative Care
Weight loss surgery is usually performed through minimally invasive methods (laparoscopic surgery). That means small incisions, faster healing and less pain and scarring than you would have with traditional open surgery.
Bariatric surgery is one of the best tools we have that can help unhealthy obese people achieve drastic weight loss. However, in order to sustain long-term results, reducing 80 to 90 percent of one’s stomach is just a part of it. If you don’t align your mind and your heart with changing your eating habits and your lifestyle, efforts for all parties are unsuccessful. The patient must exercise and practice good nutrition by eating the right portions and number of calories.
You'll lose weight quickly with weight loss surgery, but bariatric surgery is only one component of a multipronged treatment for obesity.
Postoperative Care
During the first year after your surgery, your healthcare provider will see you regularly for follow-up visits and testing. They will take metabolic blood tests to monitor how your health is improving and screen for any nutritional deficiencies. After the first year, if you're in good health and have lost a lot of weight, you may want to discuss body contouring options with your healthcare provider. Body contouring can help remove excess skin folds and tighten loose tissues.
Right away! To start, you will take easy, short walks while you are in the hospital. The key is to start slow. Listen to your body and your surgeon. As we age, lack of activity can lead to being frail or fragile, which is quite dangerous to overall health. Most patients also think of exercise as something that must be intense and painful (like “boot camp”). Regular, modest activity is far more useful in the long term. Even elite athletes can’t stay at a “peak” every week of the year. Instead, work with your surgeon’s program to find a variety of activities that can work for you. There is no “one-size-fits-all” plan.
Potential Complications and Considerations
About 30% of weight loss surgery patients regain much of the weight they lost within five years of surgery. That means an estimated 70% maintain their weight loss. Most weight loss happens in the first eight to 12 months after surgery, regardless of the patient's lifestyle habits. That's what Dr. Lyass calls the honeymoon period. Unfortunately, the hormonal effects of surgery diminish over time. If you don't change your relationship with food and watch your portion sizes, you're likely to regain the weight a few years down the road," says Dr.
Birth control pills do NOT work as well in patients who are overweight. Birth control pills are not very reliable during the time your weight is changing. For this reason, having an IUD or using condoms and spermicide with ALL intercourse is needed. After surgery, there is much less risk of experiencing problems during pregnancy and during childbirth. Kids born after mom’s surgery are LESS at risk of being affected by obesity later, due to activation of certain genes during fetal growth.
The reasons for hair loss are not totally understood. Even if you take all recommended supplements and meet protein requirements, hair loss will be noticed until the follicles come back.
There is a small group of patients after weight loss surgery who have a problem with alcohol abuse. If you feel drinking alcohol may be an issue for you after surgery, please contact your primary care doctor or surgeon and discuss this further. It has been found in scientific research that a small percentage of weight loss surgery patients report having problems with alcohol after surgery (7-10%). Many who abuse alcohol after surgery had problems with alcohol abuse at some time prior to surgery, but occasionally alcohol problems can arise in patients who never had such issues before their surgery. Alcohol sensitivity is increased after weight loss surgery so that the effects of alcohol are felt with fewer drinks than before surgery. Studies also find that with certain weight loss procedures (such as the gastric bypass or sleeve gastrectomy), drinking an alcoholic beverage increases blood alcohol to levels that are considerably higher than before surgery or in comparison to the alcohol levels of individuals who have not had a weight loss procedure. In addition, studies have found that alcohol takes much longer to clear out of a person’s system if they have had weight loss surgery, which can pose safety and legal hazards for driving. Furthermore, it has been found that some patients may feel as though they are sober (‘not drunk’) even when they are over the legal blood alcohol limit for driving.
After surgery, most patients have improved mental health but there may be a small increase in the risk of suicide. People affected by severe obesity who are seeking weight loss surgery are more likely to suffer from depression or anxiety and to have lower self-esteem and overall quality of life than someone who is normal weight. Weight loss surgery results in significant improvement in mental health for the majority of patients. However, studies have found a small but significant increase in suicide following weight loss surgery. In some cases, these may have been patients with undiagnosed mental disorders, and in others, patients may have experienced major life stressors that can increase the risk for suicide, but in rare cases, the suicides are unexplained. For this reason, comprehensive bariatric programs require psychological evaluations prior to weight loss surgery. Many programs have therapists available for patient counseling after surgery.
Nutritional Considerations
No. Most people think of a “diet” as a plan that leaves you hungry. Eventually, most patients get some form of appetite back 6-18 months after surgery. This does not mean you can whatever and whenever you want.
No. You may need higher doses of certain vitamins or minerals, especially Iron, Calcium, and Vitamin D. You will also need to have at least yearly lab checks. Insurance almost never pays for vitamin and mineral supplements but usually does pay for labs. Weight loss surgery can lead to reduced amounts of vitamins and minerals because people eat less and may absorb less in the intestines. Weight loss surgeries have different effects on vitamins and minerals based on how much change in absorption they cause. Fortunately, nutrient deficiencies following surgery can be easily avoided with a good diet and the use of supplements including vitamins, minerals, and sometimes protein supplements. Before and after surgery, patients are advised of the appropriate diet and vitamin supplement needed. Most weight loss surgery programs also require patients to have their vitamins and minerals checked on a regular basis after surgery. Nutrient deficiencies and any associated health problems are preventable with monitoring and patients following diet and supplement (vitamin and mineral) recommendations. Health problems due to deficiencies usually occur in patients who do not regularly follow-up to monitor healthy vitamin and mineral levels.
Effectiveness and Safety
Many people who suffer from obesity find it hard to lose weight and keep the weight off with diet and exercise alone. The National Institutes of Health (NIH) Expert Panel stated that, without surgery, long-term weight loss is nearly impossible for those affected by severe obesity. Studies show little long-term success with diet and exercise alone.(3) Weight loss surgeries are effective in maintaining long-term weight loss, in part, because these procedures change the body’s natural responses to dieting that make weight loss so difficult. When a person goes on a diet, their body produces more hormones that cause an increase in hunger and a decrease in calories burned. This decrease in calories the body burns is more than explained by the decrease in body size. Therefore, there are significant differences between someone who has lost weight by diet and someone of the same size who has never lost weight. For example, the body of the person who reduces their weight from 200 to 170 pounds burns fewer calories than the body of someone weighing 170 pounds who has never been on a diet. This means that in order to maintain weight loss, the person who has been on a diet will have to eat fewer calories than someone who naturally weighs the same.
Weight loss procedures, unlike diet, also cause biological changes that help reduce food intake. Energy (in the form of food) intake is decreased with surgery by restricting stomach size and limiting absorption. In addition, weight loss surgery changes the production of certain gut hormones (or signals) that communicate with the brain to reduce hunger, decrease appetite, and enhance the feeling of being full. In these ways, weight loss surgery, unlike dieting, produces long-term weight loss.
No. Weight loss surgery is very safe and decreases the chance of dying from obesity. A recent study of 209,116 patients found the risk of death from weight loss surgery was 0.16%, or approximately 1 in 600. This rate is considerably less than most other surgeries, including gallbladder and hip replacement surgery. Large studies find that the risk of death from any cause is considerably less for patients after weight loss surgery than for those who have severe obesity and have never had the surgery. Patients who have weight loss surgery have a reduction in their risk of death by 40%. Death related to diabetes is reduced by more than 90% and from heart disease by more than 50% for patients after weight loss surgery. The benefits of weight loss surgery far outweigh the risks.
Expected Weight Loss
How much weight do you lose with bariatric surgery?Most people - about 90% - lose about 50% of their excess weight after bariatric surgery, and keep it off. Different procedures have slightly different results. The average weight loss after gastric bypass is about 70% of excess body weight. After a duodenal switch, it’s about 80%. Weight loss after sleeve gastrectomy ranges between 30% and 80%.
Finding a Center of Excellence
Jackson South and Jackson North are both certified as a Center of Excellence in bariatrics, which means there are minimal complications, far fewer than the national average. We perform a high volume of surgeries and procedures, often ranging from 80 to 90 per month, so this is our daily work. Getting the surgery done in a Center of Excellence makes a huge difference. The staff is highly trained, and it is important for a patient to see qualified professionals. At Jackson, we have a team that includes surgeons, nurses, nutritionists, psychologists and more.