Bariatric Surgery Guide

Introduction to Bariatric Weight Loss Surgery

Bariatric surgery is a term derived from the Greek words: weight and treatment. In simple terms, bariatrics concerns the causes, prevention and treatment of severe overweight, a condition known as obesity. Bariatric operations are major gastrointestinal procedures which alter the capacity and/or the anatomy of the digestive system. Some bariatric procedures are performed using general anesthesia via a midline abdominal incision. Some bariatric surgeons also use laparoscopic surgical techniques, involving smaller instruments connected to cameras through which they view the operational site. The two types of bariatric surgeries are (1) restrictive – like Lap Band®, and (2) combined restrictive and malabsorptive – such as Roux-en-Y gastric bypass. The first type of surgical procedure simply reduces the size of the stomach, using staples and/or a band, resulting in a drastic reduction in the quantity of food it can ingest. The second reduces stomach capacity and bypasses the upper part of the small intestine, causing a reduction in the number of calories and nutrients which the body absorbs. Stomach bypass operations differ in both how the stomach is sectioned (stapling, banding or gastrectomy), and how much of the duodenum and jejunum are bypassed. Currently, most obesity clinics and bariatric centers favor the Lap Band adjustable gastric banding procedure and the Proximal Roux-en-Y Gastric Bypass. Obesity experts estimate that patients undergoing gastric bypass and gastric bands will exceed 175,000 in 2007.

How Does Bariatric Surgery Affect The Digestive Process?

Before Surgery
Food is chewed in the mouth, then swallowed, passing through the esophagus to the stomach, (roughly the size of a melon) where stomach acids dissolve it into smaller particles. The liquid (chyme) then passes into the small intestine where enzymes and bile continue the digestive process. The first section is the duodenum, the shortest section. Here, calcium, iron and a few vitamins are absorbed. The second and third sections are the jejunum and ileum, both about ten feet in length. Here, the bulk of food nutrients (vitamins and minerals) and calories are absorbed.

After Surgery
During both main types of obesity surgery, the size of the stomach is reduced by up to 90 percent, to the size of an egg or even the size of a thumb. Typically, its capacity is 3-4 tablespoons of food. This stomach reduction drastically reduces the quantity of food which can be consumed in one sitting and speeds up satiety. During bypass surgery, the digestive tract below the stomach is also altered. After leaving the small stomach pouch, food is re-routed to bypass most of the duodenum and is directed into the final part of the jejunum. Because the food passes along a much reduced length of small intestine, and comes into contact with smaller amounts of digestive enzymes, fewer calories and nutrients are absorbed.

Is Bariatric Surgery An Easy Solution for Weight Loss?

No. According to the American Society For Bariatric Surgery, gastric reduction surgery is not an easy option for obesity sufferers. It is a drastic step, and carries the usual pain and risks of any major gastrointestinal surgical operation.

Does Bariatric Surgery Involve New Eating Habits?

Yes. All types of gastrointestinal obesity surgery compel patients to change their eating habits radically, and make them very ill if they overeat. And after bariatric surgery is performed, patients remain at a lifelong risk of nutritional deficiencies.

Does Bariatric Surgery Typically Lead to Major Weight Loss?

Yes and No. Some patients who undergo bariatric gastrointestinal surgery lose more than 100 pounds in weight – some lose as much as 200 pounds weight. Typically, patients who undergo adjustable gastric banding procedures, such as Lap-Band lose less weight than those who have gastric bypass like Biliopancreatic Diversion (BPD) or Duodenal Switch (BPD-DS). Some patients reach a normal weight, while others remain overweight, although less overweight than before. However, in order to maintain this type of weight reduction, patients must follow carefully the post-operative guidelines relating to diet and exercise.

Who Is A Candidate for Bariatric Weight Loss Surgery?

Some bariatric surgeons accept patients in their 60’s, and some even operate on teenagers. But because bariatric surgery is a last-gasp treatment solution for obesity, to be used when conventional weight loss programs have been tried and failed, candidates must have severe obesity-related health problems.

  • Typically, to qualify for bariatric surgery you must be ‘morbidly obese’, which usually means being overweight by 100 pounds (man) or 80 pounds (woman) with a Body Mass Index (BMI) of 40+.
  • Alternatively, bariatric surgery may be appropriate if you are 80 pounds overweight (BMI 35+) and have a serious obesity-related condition like type 2 diabetes or life-threatening cardio-pulmonary problems such as severe sleep apnea or obesity-related heart disease.

Is Hospitalization Necessary Before Undergoing Bariatric Surgery?

Not usually, although patients with extremely severe obesity (End Stage obesity syndrome) may need to be hospitalized before undergoing weight loss surgery in order to lower the health risks of surgery.

Is Obesity Surgery Dangerous?

Yes. Both types of bariatric surgery (gastric banding and gastric bypass) involve major operations lasting one to two hours (longer if performed laparoscopically) and patients typically need three to five nights in hospital. The first night following the operation is usually spent in a high dependency unit or intensive care environment. (Note: After laparoscopic bariatric surgery, patients typically remain in hospital for 2-3 days, rather than the 4-5 days after open surgery. Patients typically return to work after 2-3 weeks, compared to 4-6 weeks after open surgery.) The level of health risk varies according to patient condition, type of procedure and the experience of the surgeon. (Patients are five times more likely to die if the surgeon has less experience, per University of Washington Study.) But in general, bariatric surgeries carry all the possible health risks of any major medical operation.

Do Bariatric Patients Regularly Suffer From Health Complications?

Typically, it depends upon patient-condition, the complexity of the specific operation and the skill and experience of the surgeon. Recent research suggests that 4 out of 10 patients suffer complications within six months of surgery. Of these patients, up to 20 percent required re-hospitalization to treat specific problems relating to their stomach bypass or gastric banding procedure. As well as perioperative and post-operative health problems, patients should expect to face a number of longer term physical and emotional problems. To begin with, the recommended post-operative diet regime requires an immediate and drastic change of eating habits. Gastric bypass also necessitates nutritional supplementation for life. Secondly, after losing a significant amount of weight, patients typically experience a distressing amount of loose skin. Removal will require cosmetic/plastic surgery. Your surgeon and/or the staff at your obesity clinic will advise you about the specific weight-related health issues you are likely to face.

Are The Health Risks Of Bariatric Surgery Greater Than The Risks Of Obesity?

For most patients suffering from morbid obesity (BMI 40+), super-obesity (50+) or end stage obesity syndrome (BMI 60+), the big question is, do the benefits of bariatric surgery outweigh its risks? The answer is Yes. Severe obesity is a chronic, frequently progressive, life threatening disease, and the known health risks associated with morbid obesity far outweigh the risks associated with surgery. Published studies indicate that someone who is 100 percent above his/her ideal weight has a risk of mortality ten times higher that of a person of normal weight. By comparison, the mortality rate for both vertical banded gastroplasty, adjustable gastric banding and roux-en-y gastric bypass is less than one percent. Morbidity (ie. rate of disease) in the immediate post-operative period is roughly ten percent or more, although the combined risk of the most serious complications is less than three percent. In the later postoperative period, other health complications can and do arise, and may require corrective surgical treatment. Also, some patients are unable to comply with post-operative eating and exercise guidelines over the long term. But in general the overriding health benefit of bariatric treatment is now well established.

How Important Is Patient Attitude For The Success Of Bariatric Surgery?

Very important! The higher the motivation of patients to lose weight and manage the post-operative requirements of dietary modification and behavioral therapy, the more successful surgery is likely to be, in solving their obesity and weight problems. The pre-op screening process adopted by obesity clinics to identify good candidates for bariatric surgery, is strongly influenced by patient attitude.

What Is The Cost of Bariatric Weight Loss Surgery?

Bariatric gastrointestinal surgical operations cost about $25,000 or more, depending on the experience of the surgeon, the medical team, the surgical procedure and the level of post-op services chosen.

Is Bariatric Surgery Covered By Health Insurance?

Health insurers are slowly beginning to accept that obesity surgery can deliver powerful medical benefits that will save them money in the long run, especially where convention weight loss remedies have consistently failed to reduce obesity. Therefore in several states, obesity surgeries like gastric bypass and lap band are covered by most medical insurance plans. However, patients may need to work closely with their surgeon or clinic to submit the necessary forms to the health insurance company in order to receive authorization for weight loss surgery. This includes a Letter of Medical Necessity which typically (a) Patient’s weight (BMI 40+ or 35+ with health complications), (b) List of obesity-related medical symptoms (eg. type 2 diabetes, sleep apnea, raised blood pressure, high blood fats, insulin problems), (c) How long patient has been overweight (at least five years), (d) History of failed weight-loss programs, with details of type of program, whether or not medically supervised, amount of weight lost.

Are Cosmetic or Plastic Surgery Operations Covered By Health Insurance?

No. Post-op plastic surgery procedures (like abdominoplasty, tummy tuck etc.) to remove loose skin caused by massive weight loss, are deemed to be ‘cosmetic’ rather than health related operations. As a result they are not usually covered by medical insurance plans.

What Do Doctors Think About Surgical Treatment For Obesity?

Many of the current standards and guidelines for performing bariatric surgery were set in 1991, by a Consensus Panel of physicians, sponsored by the National Institutes of Health (NIH). In particular, they established the body mass index (BMI) as the basis for selecting candidates for surgical treatment, to which was added the presence of severe comorbid conditions. The panel also stated the necessity for patients to receive multidisciplinary care by a team of doctors and therapists, to handle their weight-related co-morbidities, and emotional needs. Bariatric operations were viewed as a means of enabling patients to change their lifestyle and eating habits, in order to reduce and manage their obesity. Since 1991, there have been significant developments in the field of gastric reduction surgery, especially laparoscopy. As a result, a new Consensus Conference, sponsored by the American Society for Bariatric Surgery (ASBS), was held in 2004, which updated the evidence and the conclusions of the NIH consensus panel. They concluded that: (1) Bariatric surgery is the most effective treatment for severe clinical obesity. (2) Stomach bypass is one of four types of surgical treatment for morbid obesity. (3) Laparoscopic surgery is as effective and as safe as traditional open surgery. (4) Bariatric patients should receive comprehensive pre-op assessment, and multi-disciplinary post-op support, in order to achieve the best weight loss results.

Should You Have Bariatric Surgery?

The health dangers of severe obesity are well documented. Words like globesity and diabesity are evidence of the growing impact of this body-fat disease. Also, statistics show that severely obese patients have little chance of losing weight using conventional diets. However, this does not mean that bariatric surgery is a guaranteed solution for obesity. Long term studies of bariatric patients suggest that 1 in 2 fail to maintain any significant weight loss, and many patients regain all the weight they lose. Patients who have realistic expectations, a positive attitude and, above all, a genuine commitment to making lifelong changes in their attitude to food and exercise, typically achieve much better results.

Inform Yourself About Bariatric Surgery

Do not believe everything you read about bariatric surgery. Before taking any decisions, talk with patients who have undergone this form of weight loss surgery. Find out about the problems, issues and health risks involved. Listen carefully to the advice offered by your obesity clinic. When choosing a clinic, always inquire about what post-op support services they offer, such as counseling, email or forum support.