For many individuals struggling with obesity, weight loss surgery, also known as bariatric or metabolic surgery, presents a viable path toward improved health and well-being. The decision to undergo weight loss surgery is significant, necessitating careful consideration of the various procedures available, their respective risks and benefits, and long-term lifestyle adjustments. This article aims to provide a comprehensive overview of the safest weight loss surgery options, drawing on research and expert recommendations to guide informed decision-making.
The Role of Bariatric Surgery
Weight loss surgery is a transformative experience that offers advantages extending far beyond a lower number on the scale. For individuals with obesity, particularly those with related conditions like type 2 diabetes, high blood pressure, and heart disease, losing weight can be critical. While diet and exercise are essential for maintaining a healthy weight, some individuals find it challenging to achieve significant weight loss through these methods alone. In such cases, bariatric surgery can be an effective tool to lower and manage weight.
Bariatric surgery modifies the stomach and, in some cases, the small intestine to limit calorie intake and absorption. These operations are very effective in treating diabetes, high blood pressure, sleep apnea, and high cholesterol, and they can also prevent future health problems.
Understanding Different Types of Weight Loss Surgery
Several types of weight loss surgery are available, each with its own advantages and potential drawbacks. The most common procedures endorsed by the American Society for Metabolic and Bariatric Surgery include:
Roux-en-Y Gastric Bypass
The Roux-en-Y gastric bypass has been performed for over 50 years, and the laparoscopic approach has been refined since 1993. It is one of the most common operations and is very effective in treating obesity and obesity-related diseases.
Read also: Principles of Diet Planning
In this procedure, the surgeon creates a small pouch at the top of the stomach, about the size of an egg, which becomes the only part of the stomach that receives food. The small intestine is then divided and connected to the new stomach pouch to allow food to pass. The gastric bypass works in several ways. Like many bariatric procedures, the newly created stomach pouch is smaller and able to hold less food, which means fewer calories are ingested. Additionally, the food does not come into contact with the first portion of the small bowel, which results in decreased absorption. Most importantly, the modification of the food course through the gastrointestinal tract has a profound effect to decrease hunger, increase fullness, and allow the body to reach and maintain a healthy weight. The impact on hormones and metabolic health often results in improvement of adult-onset diabetes even before any weight loss occurs. The operation also helps patients with reflux (heartburn), and often the symptoms quickly improve.
Pros:
- Significant weight loss
- Considered the gold standard treatment for morbid obesity
- Possible to reverse the surgery if severe problems arise
Cons:
- Increased risk of bleeding complications due to the two-step nature of the surgery
- Longer recovery time and more time on the operating room table
- Higher risk of dumping syndrome
- Malabsorption is more likely
- Patients cannot take nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen
Sleeve Gastrectomy
The Laparoscopic Sleeve Gastrectomy, often called the “sleeve”, is performed by removing approximately 80% of the stomach. The new stomach holds less food and liquid, helping reduce the amount of food (and calories) that are consumed. By removing the portion of the stomach that produces most of the “hunger hormone”, the surgery has an effect on the metabolism. It decreases hunger, increases fullness, and allows the body to reach and maintain a healthy weight as well as blood sugar control.
A sleeve gastrectomy changes the stomach's size but doesn’t alter the small intestine, like gastric bypass. The surgeon reshaped the stomach into a small pouch, shaped like a sleeve, and removes the stomach's remaining part. Food goes through the stomach normally into the duodenum since there is no alteration of the small intestine.
By changing the size of the stomach, you get full faster. Also, this surgery has the same hormonal impact as a gastric bypass. You will be less hungry even though you eat fewer calories.
The removal of part of the stomach is permanent, so any complications that occur may be too. There is no way to reverse the procedure and return the stomach to normal size. Also, sleeve gastrectomy can lead to acid reflux that is difficult to control.
Read also: Alternatives to Fad Diets
Pros:
- Not as complex as gastric bypass
- Shorter surgery time compared to gastric bypass
- Fewer malabsorption issues
- Less risk of dumping syndrome
- Effective for weight loss
Cons:
- The surgeon removes that lower portion of the stomach, making the procedure nonreversible
- Some people experience stomach discomfort with this procedure, such as heartburn or gas. Some also develop difficulty swallowing
Adjustable Gastric Banding
The Adjustable Gastric Band is a device made of silicone that is placed around the top part of the stomach to limit the amount of food a person can eat. It has been available in the United States since 2001. The impact on obesity-related diseases and long-term weight loss is less than with other procedures. The feeling of fullness depends upon the size of the opening between the pouch and the rest of the stomach. The opening size can be adjusted with fluid injections through a port underneath the skin. Food goes through the stomach normally but is limited by the smaller opening of the band.
Adjustable gastric banding uses a silicon band to separate the stomach into a small and large pouch. A port attached to the abdominal wall allows saline to restrict the size of the food passage to control how much you can eat.
Unlike gastric bypass and sleeve gastrectomy, this procedure does not surgically alter the stomach's anatomy. Instead, a band separates the stomach into an upper and lower section. This restricts the amount of food you can eat at one time.
Of all the available weight-loss surgeries, this one has the lowest average weight loss associated with it. The average weight loss with gastric bypass is 71 percent of excess weight but just 55 percent with adjustable gastric banding. One study published in American Family Physician indicates that 20 percent of adjustable gastric banding procedures fail completely.
However, it is an easily reversed procedure, so if something goes wrong, a surgeon can remove the band, and you can still consider other bariatric surgery types.
Read also: Energy Consumption and Diets
Pros:
- Adjustable gastric banding does not require any cutting into the stomach or intestine. There are small surgical incisions, though, and a stoma, a small hole in the abdominal wall.
- It is completely reversible.
- Since the goal is only to restrict food intake, it doesn’t have complications associated with bariatric surgery, such as malabsorption and dumping syndrome.
Cons:
- Has a lower success rate than both gastric bypass and sleeve gastrectomy.
- The band can cause complications, such as slippage or erosion.
- To access the port attached to the band, the surgeon creates a stoma or opening in the abdominal wall. There can be complications with the stoma, as well, such as irritation, infection, or blockage.
- Since the band is a foreign object, it’s possible your body may not respond well to it, too. Scar tissue can develop. Band intolerance can cause nausea and vomiting.
- Lower weight loss than other bariatric surgeries
- The band may need adjustments or saline refills.
Biliopancreatic Diversion with Duodenal Switch (BPD-DS)
The Biliopancreatic Diversion with Duodenal Switch, abbreviated BPD-DS, begins with creation of a tube-shaped stomach pouch similar to the sleeve gastrectomy. The smaller stomach, shaped like a banana, allows patients to eat less food. The food stream bypasses roughly 75% of the small intestine, the most of any commonly performed approved procedures. This results in a significant decrease in the absorption of calories and nutrients. Patients must take vitamins and mineral supplements after surgery. Even more than gastric bypass and sleeve gastrectomy, the BPD-DS affects intestinal hormones in a manner that reduces hunger, increases fullness and improves blood sugar control.
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.
Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy (SADI-S)
The Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy, referred to as the SADI-S is the most recent procedure to be endorsed by the American Society for Metabolic and Bariatric Surgery. A loop of intestine is measured several feet from its end and is then connected to the stomach. When the patient eats, food goes through the pouch and directly into the latter portion of the small intestine. The food then mixes with digestive juices from the first part of the small intestine. This allows enough absorption of vitamins and minerals to maintain healthy levels of nutrition.
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.
Endoscopic Procedures
Endoscopy is a procedure where doctors insert a thin, flexible tube equipped with a camera through your mouth into your digestive tract. This allows them to access your digestive system without open surgery, which carries higher risk.
Endoscopic weight loss procedures work by allowing doctors to place special devices or medications into the gastrointestinal tract to limit how much you can eat. Unlike bariatric weight loss surgery, which can require months of prep and several days of recovery, endoscopy is a one-day procedure.
One of the most common endoscopic weight loss procedures is the gastric balloon. This treatment places a silicone balloon in the stomach to take up volume. Gastric balloons can make you feel fuller longer. Doctors leave the balloon in place for about six months and patients can expect to lose up to 15 percent of their body weight. It’s not for everyone: People who have a hiatal hernia or previous gastric surgery are not eligible for the gastric balloon.
During an endoscopic sleeve gastroplasty, a specialist places stitches inside the stomach to reduce its volume by 70 percent. The patient is completely asleep under general anesthesia for the procedure.
Gastric injections work by freezing the stomach muscles, which slows digestion and helps patients feel fuller faster.
Safety and Effectiveness: Key Considerations
When evaluating the safest weight loss surgery options, it's essential to consider both the risk of complications and the effectiveness of each procedure in achieving sustainable weight loss.
Gastric Sleeve: A Promising Option
Research suggests that gastric sleeve surgery has a lower risk of complications and a higher effectiveness for weight loss. In one major study from 2018, gastric sleeve surgery was found to be the safest procedure with the lowest risk of side effects compared to gastric bypass and gastric band surgery. The rates of side effects within 30 days after the surgery were 5% for gastric bypass surgery, 2.9% for gastric band surgery, and 2.6% for gastric sleeve surgery. The study also found that gastric bypass resulted in more than 31% total weight loss after a year, with gastric sleeve and gastric band at 25.2% and 13.7% respective weight loss after a year.
Gastric Bypass: Effective but with Higher Risks
Gastric bypass surgery is associated with the highest average total weight loss percentage after 1 year. However, it also carries a higher risk of complications compared to gastric sleeve surgery. In the 2018 study, gastric bypass surgery was associated with the highest percentage of side effects after the procedure.
Gastric Banding: Lower Impact on Weight Loss
Research studies suggest that gastric banding tends to have the lowest impact on weight loss. In one early study from 2014, researchers found that gastric band surgery was associated with a high percentage of failure, with roughly 31% of people not experiencing clinical weight loss and another 13% undergoing band removal.
Minimally Invasive Techniques
Most modern weight loss surgeries are performed laparoscopically. Laparoscopic surgery refers to a type of surgery using specialized tools with a camera that are inserted into small incisions, or openings, in your body.
Research suggests that laparoscopic surgery is less invasive, safer, and more effective than open surgery. It’s associated with shorter recovery times, less pain, fewer complications, and a lower risk of death.
Some weight loss procedures may also be performed endoscopically. Endoscopic surgery uses instruments that are inserted into your mouth to access various areas of your digestive tract.
One study from 2022 found that endoscopic bariatric surgery had lower side effect rates, surgery length, and length of stay than laparoscopic bariatric surgery.
Factors Influencing the Choice of Surgery
The choice of weight loss surgery depends on various factors, including:
- BMI (Body Mass Index): Individuals with a BMI over 40 or over 35 with obesity-related health conditions may be candidates for surgery.
- Overall Health: The individual's overall health and medical history play a crucial role in determining the suitability of different procedures.
- Personal Preferences: Individual preferences and risk tolerance should also be considered.
- Surgeon's Recommendation: Consulting with a qualified bariatric surgeon is essential to discuss the options and determine the most appropriate procedure.
Qualifying for Bariatric Surgery
Bariatric surgery requirements begin with establishing a diagnosis of class III obesity. That means that you either:
- Have a BMI of 40 or higher.
- Have a BMI of at least 35 and at least one related health problem.
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.
Common Myths About Bariatric Surgery
It's important to dispel common myths 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 is a tool that allows a healthy diet and lifestyle to lead to sustained weight loss.
Preparing for Bariatric Surgery
Before scheduling 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.
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.
The preparation process for bariatric surgery includes education, evaluations, pre- and post-operative activities, and a life-long commitment to a lifestyle that will maintain weight loss and long-term health. The pre-operative journey usually takes 4-6 months after you first meet with a bariatric surgeon.
Postoperative Care and Lifestyle Adjustments
Successful bariatric surgery requires a team-based approach including your surgeon, dietitian, psychologist, nurse case manager, and obesity medicine specialist who will focus on taking you through each step of the journey. Patients will do better if they continue to eat healthy, engage in physical activity, keep their appointments with obesity medicine providers, and take vitamins and mineral supplements as instructed. Your bariatric care team will provide you with lifelong support to succeed and maintain a permanent healthy lifestyle including changes to your diet and regular physical activity.
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.
Potential Complications
All surgeries have the potential for complications, but here are some of the frequently noted complications of bariatric surgery:
- Bleeding
- Blood clots
- Infection
- Obstructions
- Stomach leakage
- GERD
- Stricture
- Stenosis
- Stomach twists or kinks
- Hernia
- Stomach ulcer
- Nutritional deficiencies
- Hypoglycemia
- Peripheral neuropathy
- Osteoporosis
- Complication with gastric banding, band slippage, or band erosion
Revisional Surgery
Revisional bariatric surgery is a procedure to reverse or modify an earlier weight loss surgery. It is typically done because the earlier procedure failed in some way. It may have produced disappointing outcomes or an undesirable effect. Studies indicate that between 5 to 8 percent of weight loss surgeries fail and require revisional procedures to correct or reverse them.
Some common reasons to have revisional surgery include:
- Inadequate weight loss
- Weight gain
- Anastomotic stricture
- Stomal stricture
- Difficulty swallowing
- Frequent vomiting
- Ulcers
- Reflux
- Gastric dilation or enlargement
- Esophageal dilation
- Band erosion or slippage
- Gastro-gastric fistula
- Hernia
- Bowel obstruction
How the revisional procedure works will depend on the original bariatric surgery. In some cases, reversible surgery means converting one procedure to another. For instance, someone having problems with an adjustable band might have revisional surgery that includes gastric bypass. The goal of revisional surgery might be to modify the original procedure. For example, making the “sleeve” in a sleeve gastrectomy smaller.
Revisional surgery might completely reverse either a gastric bypass or an adjustable gastric band. Simply reversing the original surgery would likely lead to significant weight gain, though, so converting to a different type of bariatric procedure is often the goal.
Benefits of Bariatric Surgery
Losing weight is not the only perk of having bariatric surgery. Overall quality of life, self-confidence and energy levels can skyrocket-while many obesity-related health conditions can be avoided, improved or completely resolved! Bariatric surgery is the most effective tool for weight loss for many people.
Just 2 percent of bariatric patients who rely on diet and exercise alone are able to lose weight and keep it off, compared with up to 80 percent of people who undergo bariatric surgery. The amount of weight loss is also significant: Gundersen patients lose about 72 percent of excess weight by the end of the first year after surgery.
Weight loss surgery at Gundersen Health System is minimally invasive. This means that small incisions are made to complete the procedure-unlike when you undergo open surgery. Minimally invasive surgery typically results in fewer complications, less pain and a quicker recovery. Most people leave the hospital just one night after their procedure and require very little pain medication afterward.