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A Guide to Bariatric Surgery: Table of Contents
Bariatric Surgery IntroductionPage 01
What is Obesity?Page 02
What is Morbid Obesity?Page 03
Causes of Morbid ObesityPage 04
Health Threats of Morbid ObesityPage 05
Obesity Related Health ConditionsPage 06
Am I Morbidly Obese?Page 07
FAQ's about Morbid ObesityPage 08
Options for TreatmentPage 09
How Surgery Reduces WeightPage 10
The Gastrointestinal TractPage 11
Weight Loss SurgeryPage 12
Weight Loss Surgery OptionsPage 13
How Effective is SurgeryPage 14
Risks of SurgeryPage 15
Where to BeginPage 16
Choosing SurgeryPage 17
The Importance of SupportPage 18
Preparation for SurgeryPage 19
The Hospital StayPage 20
Life After SurgeryPage 21

Bariatric Surgery

Morbid obesity is a chronic disease, meaning that its symptoms build slowly over an extended period of time. An estimated 5-10 million Americans are considered morbidly obese. Obesity becomes "morbid" when it reaches the point of significantly increasing the risk of one or more obesity-related health conditions or serious diseases (also known as co-morbidities) that can result either in significant physical disability or even death.

Weight loss surgery is major surgery. Its growing use to treat morbid obesity is the result of three factors: Our current knowledge of the significant health risks of morbid obesity; the relatively low risk and complications of the procedures versus not having surgery; and the ineffectiveness of current non-surgical approaches to produce sustained weight loss. This site will provide valuable information about the benefits and risks of weight loss surgery. However, the best way to get a full assessment of your condition is to schedule a consultation to determine if weight loss surgery may be an option for you.

What Is Obesity?

Obesity results from the excessive accumulation of fat that exceeds the body's skeletal and physical standards. According to the National Institutes of Health (NIH), an increase in 20 percent or more above your ideal body weight is the point at which excess weight becomes a health risk. Today 97 million Americans, more than one-third of the adult population, are overweight or obese. An estimated 5 to 10 million of those are considered morbidly obese.

What Is Morbid Obesity?

Obesity becomes "morbid" when it reaches the point of significantly increasing the risk of one or more obesity-related health conditions or serious diseases (also known as co-morbidities) that result either in significant physical disability or even death. As you read about morbid obesity you may also see the term "clinically severe obesity" used. Both are descriptions of the same condition and can be used interchangeably. Morbid obesity is typically defined as being 100 lbs. or more over ideal body weight or having a Body Mass Index of 40 or higher. According to the National Institutes of Health Consensus Report, morbid obesity is a serious disease and must be treated as such. It is a chronic disease, meaning that its symptoms build slowly over an extended period of time.

Causes of Morbid Obesity

The reasons for obesity are multiple and complex. Despite conventional wisdom, it is not simply a result of overeating. Research has shown that in many cases a significant, underlying cause of morbid obesity is genetic. Studies have demonstrated that once the problem is established, efforts such as dieting and exercise programs have a limited ability to provide effective long-term relief.

Science continues to search for answers. But until the disease is better understood, the control of excess weight is something patients must work at for their entire lives. That is why it is very important to understand that all current medical interventions, including weight loss surgery, should not be considered medical cures. Rather they are attempts to reduce the effects of excessive weight and alleviate the serious physical, emotional and social consequences of the disease.


 

Contributing Factors

The underlying causes of severe obesity are not known. There are many factors that contribute to the development of obesity including genetic, hereditary, environmental, metabolic and eating disorders. There are also certain medical conditions that may result in obesity like intake of steroids and hypothyroidism.


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Genetic Factors

Numerous scientific studies have established that your genes play an important role in your tendency to gain excess weight.

  • The body weight of adopted children shows no correlation with the body weight of their adoptive parents, who feed them and teach them how to eat. Their weight does have an 80 percent correlation with their genetic parents, whom they have never met.
  • Identical twins, with the same genes, show a much higher similarity of body weights than do fraternal twins, who have different genes.
  • Certain groups of people, such as the Pima Indian tribe in Arizona, have a very high incidence of severe obesity. They also have significantly higher rates of diabetes and heart disease than other ethnic groups.

We probably have a number of genes directly related to weight. Just as some genes determine eye color or height, others affect our appetite, our ability to feel full or satisfied, our metabolism, our fat-storing ability, and even our natural activity levels.


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The Pima Paradox

The Pima Indians are known in scientific circles as one of the heaviest groups of people in the world. In fact, National Institutes of Health researchers have been studying them for more than 35 years. Some adults weigh more than 500 pounds, and many obese teenagers are suffering from diabetes, the disease most frequently associated with obesity.

But here's a really interesting fact - a group of Pima Indians living in Sierra Madre, Mexico, does not have a problem with obesity and its related diseases. Why not?

The leading theory states that after many generations of living in the desert, often confronting famine, the most successful Pima were those with genes that helped them store as much fat as possible during times when food was available. Now those fat-storing genes work against them.

Though both populations consume a similar number of calories each day, the Mexican Pima still live much like their ancestors did. They put in 23 hours of physical labor each week and eat a traditional diet that's very low in fat. The Arizona Pima live like most other modern Americans, eating a diet consisting of around 40 percent fat and engaging in physical activity for only two hours a week.

The Pima apparently have a genetic predisposition to gain weight. And the environment in which they live - the environment in which most of us live - makes it nearly impossible for the Arizona Pima to maintain a normal, healthy body weight.

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Environmental Factors

Environmental and genetic factors are obviously closely intertwined. If you have a genetic predisposition toward obesity, then the modern American lifestyle and environment may make controlling weight more difficult.

Fast food, long days sitting at a desk, and suburban neighborhoods that require cars all magnify hereditary factors such as metabolism and efficient fat storage.

For those suffering from morbid obesity, anything less than a total change in environment usually results in failure to reach and maintain a healthy body weight.

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Metabolism

We used to think of weight gain or loss as only a function of calories ingested and then burned. Take in more calories than you burn, gain weight; burn more calories than you ingest, lose weight. But now we know the equation isn't that simple.

Obesity researchers now talk about a theory called the "set point," a sort of thermostat in the brain that makes people resistant to either weight gain or loss. If you try to override the set point by drastically cutting your calorie intake, your brain responds by lowering metabolism and slowing activity. You then gain back any weight you lost.

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Eating Disorders & Medical Conditions

Weight loss surgery is not a cure for eating disorders. And there are medical conditions, such as hypothyroidism, that can also cause weight gain. That's why it's important that you work with your doctor to make sure you do not have a condition that should be treated with medication and counseling.

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Health Threats of Morbid Obesity

Morbid obesity brings with it an increased risk for a shorter life expectancy. For individuals whose weight exceeds twice their ideal body weight (that's about 2-6% of the U.S. population), the risk of an early death is doubled compared to non-obese individuals. The risk of death from diabetes or heart attack is five to seven times greater. Even beyond the issue of obesity-related health conditions, weight gain alone can lead to a condition known as "end-stage" obesity where, for the most part, no treatment options are available. Yet an early death is not the only potential consequence. Social, psychological and economic effects of morbid obesity, however unfair, are real and can be especially devastating.

Obesity-Related Health Conditions

Obesity-related health conditions are health conditions that, whether alone or in combination, can significantly reduce your life expectancy. A partial list of some of the more common conditions follows. Your doctor can provide you with a more detailed and complete list:

  • Type 2 Diabetes. Obese individuals develop a resistance to insulin, which regulates blood sugar levels. Over time, the resulting high blood sugar can cause serious damage to the body.
  • High blood pressure/Heart disease. Excess body weight strains the ability of the heart to function properly. The resulting hypertension (high blood pressure) can result in strokes, as well as inflict significant heart and kidney damage.
  • Osteoarthritis of weight-bearing joints. The additional weight placed on joints, particularly knees and hips, results in rapid wear and tear, along with pain caused by inflammation. Similarly, bones and muscles of the back are constantly strained, resulting in disk problems, pain and decreased mobility.
  • Sleep apnea/Respiratory problems. Fat deposits in the tongue and neck can cause intermittent obstruction of the air passage. Because the obstruction is increased when sleeping on your back, you may find yourself waking frequently to reposition yourself. The resulting loss of sleep often results in daytime drowsiness and headaches.
  • Gastroesophageal reflux/Heartburn. Acid belongs in the stomach and seldom causes any problem when it stays there. When acid escapes into the esophagus through a weak or overloaded valve at the top of the stomach, the result is called gastroesophageal reflux, and "heartburn" and acid indigestion are common symptoms. Approximately 10-15% of patients with even mild sporadic symptoms of heartburn will develop a condition called Barrett's esophagus, which is a pre-malignant change in the lining membrane of the esophagus, a cause of esophageal cancer. For more information on Heartburn, its causes and possible cures, visit www.heartburnhelp.com.
  • Depression. Seriously overweight persons face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, sneers and remarks from strangers. They often experience discrimination at work, cannot fit comfortably in theatre seats, or ride in a bus or plane.
  • Infertility. The inability or diminished ability to produce offspring.
  • Urinary stress incontinence. A large, heavy abdomen and relaxation of the pelvic muscles, especially associated with the effects of childbirth, may cause the valve on the urinary bladder to be weakened, leading to leakage of urine with coughing, sneezing, or laughing.
  • Menstrual irregularities. Morbidly obese individuals often experience disruptions of the menstrual cycle, including interruption of the menstrual cycle, abnormal menstrual flow and increased pain associated with the menstrual cycle.

Am I Morbidly Obese?

Answering this question may give you the courage you need to take the first step. Below are tools you can use to determine if you are morbidly obese and potentially a candidate for weight loss surgery.

There are several medically accepted criteria for defining morbid obesity. You are likely morbidly obese if you are:

  • more than 100 lbs. over your ideal body weight, or
  • have a Body Mass Index (BMI) of over 40, or
  • have a BMI of over 35 and are experiencing severe negative health effects, such as high blood pressure or diabetes, related to being severely overweight
  • unable to achieve a healthy body weight for a sustained period of time, even through medically supervised dieting

Ideal Body Weight Chart

Male    Female
Height Ideal Weight Height Ideal Weight
4' 6" 63 - 77 lbs. 4' 6" 63 - 77 lbs.
4' 7" 68 - 84 lbs. 4' 7" 68 - 83 lbs.
4' 8" 74 - 90 lbs. 4' 8" 72 - 88 lbs.
4' 9" 79 - 97 lbs. 4' 9" 77 - 94 lbs.
4' 10" 85 - 103 lbs. 4' 10" 81 - 99 lbs.
4' 11" 90 - 110 lbs. 4' 11" 86 - 105 lbs.
5' 0" 95 - 117 lbs. 5' 0" 90 - 110 lbs.
5' 1" 101 - 123 lbs. 5' 1" 95 - 116 lbs.
5' 2" 106 - 130 lbs. 5' 2" 99 - 121 lbs.
5' 3" 112 - 136 lbs. 5' 3" 104 - 127 lbs.
5' 4" 117 - 143 lbs. 5' 4" 108 - 132 lbs.
5' 5" 122 - 150 lbs. 5' 5" 113 - 138 lbs.
5' 6" 128 - 156 lbs. 5' 6" 117 - 143 lbs.
5' 7" 133 - 163 lbs. 5' 7" 122 - 149 lbs.
5' 8" 139 - 169 lbs. 5' 8" 126 - 154 lbs.
5' 9" 144 - 176 lbs. 5' 9" 131 - 160 lbs.
5' 10" 149 - 183 lbs. 5' 10" 135 - 165 lbs.
5' 11" 155 - 189 lbs. 5' 11" 140 - 171 lbs.
6' 0" 160 - 196 lbs. 6' 0" 144 - 176 lbs.
6' 1" 166 - 202 lbs. 6' 1" 149 - 182 lbs.
6' 2" 171 - 209 lbs. 6' 2" 153 - 187 lbs.
6' 3" 176 - 216 lbs. 6' 3" 158 - 193 lbs.
6' 4" 182 - 222 lbs. 6' 4" 162 - 198 lbs.
6' 5" 187 - 229 lbs. 6' 5" 167 - 204 lbs.
6' 6" 193 - 235 lbs. 6' 6" 171 - 209 lbs.
6' 7" 198 - 242 lbs. 6' 7" 176 - 215 lbs.
6' 8" 203 - 249 lbs. 6' 8" 180 - 220 lbs.
6' 9" 209 - 255 lbs. 6' 9" 185 - 226 lbs.
6' 10" 214 - 262 lbs. 6' 10" 189 - 231 lbs.
6' 11" 220 - 268 lbs. 6' 11" 194 - 237 lbs.
7' 0" 225 - 275 lbs. 7' 0" 198 - 242 lbs.

Frequently Asked Questions About Morbid Obesity

Our Frequently Asked Questions section refers to United States-based generally standard and accepted practices. As always, please check with your healthcare provider to determine their practices, guidelines and what they recommend for you.


Preparation for Surgery

  • What are the routine tests before surgery?
    Certain basic tests are done prior to surgery: a Complete Blood Count (CBC), Urinalysis, and a Chemistry Panel, which gives a readout of about 20 blood chemistry values. Often a Glucose Tolerance Test is done to evaluate for diabetes, which is very common in overweight persons. All patients but the very young get a chest X-ray and an electrocardiogram. Women may have a vaginal ultrasound to look for abnormalities of the ovaries or uterus. Many surgeons ask for a gallbladder ultrasound to look for gallstones. Other tests, such as pulmonary function testing, echocardiogram, sleep studies, GI evaluation, cardiology evaluation, or psychiatric evaluation, may be requested when indicated.
  • What is the purpose of all these tests?
    An accurate assessment of your health is needed before surgery. The best way to avoid complications is to never have them in the first place. It is important to know if your thyroid function is adequate since hypothyroidism can lead to sudden death post-operatively. If you are diabetic, special steps must be taken to control your blood sugar. Because surgery increases cardiac stress, your heart will be thoroughly evaluated. These tests will determine if you have liver malfunction, breathing difficulties, excess fluid in the tissues, abnormalities of the salts or minerals in body fluids, or abnormal blood fat levels.
  • Why do I have to have a GI Evaluation?
    Patients who have significant gastrointestinal symptoms such as upper abdominal pain, heartburn, belching sour fluid, etc., may have underlying problems such as a hiatal hernia, gastroesophageal reflux or peptic ulcer. For example, many patients have symptoms of reflux. Up to 15% of these patients may show early changes in the lining of the esophagus, which could predispose them to cancer of the esophagus. It is important to identify these changes so a suitable surveillance or treatment program can be planned.
  • Why do I have to have a Sleep Study?
    The sleep study detects a tendency for abnormal stopping of breathing, usually associated with airway blockage when the muscles relax during sleep. This condition is associated with a high mortality rate. After surgery, you will be sedated and will receive narcotics for pain, which further depress normal breathing and reflexes. Airway blockage becomes more dangerous at this time. It is important to have a clear picture of what to expect and how to handle it.
  • Why do I have to have a Psychiatric Evaluation?
    The most common reason a psychiatric evaluation is ordered is that your insurance company may require it. Most psychiatrists will evaluate your understanding and knowledge of the risks and complications associated with weight loss surgery and your ability to follow the basic recovery plan.
  • What impact do my medical problems have on the decision for surgery, and how do the medical problems affect risk?
    Medical problems, such as serious heart or lung problems, can increase the risk of any surgery. On the other hand, if they are problems that are related to the patient's weight, they also increase the need for surgery. Severe medical problems may not dissuade the surgeon from recommending gastric bypass surgery if it is otherwise appropriate, but those conditions will make a patient's risk higher than average.
  • If I want to undergo a gastric bypass, how long do I have to wait?
    New evaluation appointments are usually booked 4-8 months in advance. Once a patient is seen, if the surgeon and patient agree it is appropriate, the operation can usually be scheduled within 8 weeks. Why so long? There is more need for weight loss surgery than there are qualified bariatric surgeons.
  • What can I do before the appointment to speed up the process of getting ready for surgery?
    • Select a primary care physician if you don't already have one, and establish a relationship with him or her. Work with your physician to ensure that your routine health maintenance testing is current. For example, women may have a pap smear, and if over 40 years of age, a breast exam. And for men, this may include a prostate specific antigen test (PSA).
    • Make a list of all the diets you have tried (a diet history) and bring it to your doctor.
    • Bring any pertinent medical data to your appointment with the surgeon - this would include reports of special tests (echocardiogram, sleep study, etc.) or hospital discharge summary if you have been in the hospital.
    • Bring a list of your medications with dose and schedule.
    • Stop smoking. Surgical patients who use tobacco products are at a higher surgical risk.
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Insurance Issues

  • Why does it take so long to get insurance approval?
    After your telephone interview consultation is completed, it usually takes your doctor 1-2 days to send a letter to your insurance carrier to start the approval process. The time it takes to get an answer can vary from about 3-4 weeks or longer if you are not persistent in your follow-up. Most treatment centers have insurance analysts who will follow up regularly on approval requests. It may be helpful for you to call the claims service of your insurance company about a week after your letter is submitted and ask about the status of your request.
  • How can they deny insurance payment for a life-threatening disease?
    Payment may be denied because there may be a specific exclusion in your policy for obesity surgery or "treatment of obesity." Such an exclusion can often be appealed when the surgical treatment is recommended by your surgeon or referring physician as the best therapy to relieve life-threatening obesity-related health conditions, which usually are covered.
    Insurance payment may also be denied for lack of "medical necessity." A therapy is deemed to be medically necessary when it is needed to treat a serious or life-threatening condition. In the case of morbid obesity, alternative treatments - such as dieting, exercise, behavior modification, and some medications - are considered to be available. Medical necessity denials usually hinge on the insurance company's request for some form of documentation, such as 1 to 5 years of physician-supervised dieting or a psychiatric evaluation, illustrating that you have tried unsuccessfully to lose weight by other methods.
  • What can I do to help the process?
    Gather all the information (diet records, medical records, medical tests) your insurance company may require. This reduces the likelihood of a denial for failure to provide "necessary" information. Letters from your personal physician and consultants attesting to the "medical necessity" of treatment are particularly valuable. When several physicians report the same findings, it may confirm a medical necessity for surgery.
    When the letter is submitted, call your carrier regularly to ask about the status of your request. Your employer or human relations/personnel office may also be able to help you work through unreasonable delays.
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Surgery

  • Does Laparoscopic Surgery decrease the risk?
    No. Laparoscopic operations carry the same risk as the procedure performed as an open operation. The benefits of laparoscopy are typically less discomfort, shorter hospital stay, earlier return to work and reduced scarring.
  • Will I have a lot of pain?
    Every attempt is made to control pain after surgery to make it possible for you to move about quickly and become active. This helps avoid problems and speeds recovery. Often several drugs are used together to help manage your post-surgery pain. While you are still in the hospital, a Patient Controlled Analgesia (PCA), which allows you to give yourself a dose of pain medicine on demand, may be used by your physician. Various methods of pain control, depending on your type of surgical procedure, are available. Ask your surgeon about other pain management options.
  • How long do I have to stay in the hospital?
    As long as it takes to be self-sufficient. Although it can vary, the hospital stay (including the day of surgery) can be 1-2 days for a laparoscopic band, 2-3 days for a laparoscopic gastric bypass, and 5-7 days for an open gastric bypass.
  • Will the doctor leave a drain in after surgery?
    Most patients will have a small tube to allow drainage of any accumulated fluids from the abdomen. This is a safety measure, and it is usually removed a few days after the surgery. Generally, it produces no more than minor discomfort.
  • If I have surgery, what can I expect when I wake up in the recovery room?
    Some doctors will provide a Patient Controlled Analgesia (PCA) or a self-administered pain management system, to help control pain. Others prefer to use an infusion pump that provides a local anesthetic in the surgical site to control pain without the side effects of narcotics. As with any major surgery, you are in danger of death from a blood clot or other surgical side effects. Statistically, the risk of death during these procedures is less than 1 percent. Your doctors will have assessed you for risks and prepared accordingly.
    All abdominal operations carry the risks of bleeding, infection in the incision, thrombophlebitis of legs (blood clots), lung problems (pneumonia, pulmonary embolisms), strokes or heart attacks, anesthetic complications, and blockage or obstruction of the intestine. These risks are greater in morbidly obese patients.
  • How soon will I be able to walk?
    Almost immediately after surgery doctors will require you to get up and move about. Patients are asked to walk or stand at the bedside on the night of surgery, take several walks the next day and thereafter. On leaving the hospital, you may be able to care for all your personal needs, but will need help with shopping, lifting and with transportation.
  • How soon can I drive?
    For your own safety, you should not drive until you have stopped taking narcotic medications and can move quickly and alertly to stop your car, especially in an emergency. Usually this takes 7-14 days after surgery.
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The Hospital Stay

  • What is done to minimize the risk of deep vein thrombosis/pulmonary embolism or DVT/PE?
    Because a DVT originates on the operating table, therapy begins before a patient goes to the operating room. Generally, patients are treated with sequential leg compression stockings and given a blood thinner prior to surgery. Both of these therapies continue throughout your hospitalization. The third major preventive measure involves getting the patient moving and out of bed as soon as possible after the operation to restore normal blood flow in the legs.
  • What should I bring with me to the hospital?
    Basic toiletries (comb, toothbrush, etc.) and clothing may be provided by the hospital, but most people prefer to bring their own. Choose clothes for your stay that are easy to put on and take off. Because of your incision, your clothes may become stained by blood or other body fluids. Other ideas:
    • reading and writing materials
    • crossword and other puzzles
    • personal toiletries
    • bathrobe
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Life After Surgery

  • What do I need to do to be successful after surgery?
    The basic rules are simple and easy to follow:
    • Immediately after surgery, your doctor will provide you with special dietary guidelines. You will need to follow these guidelines closely. Many surgeons begin patients with liquid diets, moving to semi-solid foods and later, sometimes weeks or months later, solid foods can be tolerated without risk to the surgical procedure performed. Allowing time for proper healing of your new stomach pouch is necessary and important.
    • When able to eat solids, eat 2-3 meals per day, no more. Protein in the form of lean meats (chicken, turkey, fish) and other low-fat sources should be eaten first. These should comprise at least half the volume of the meal eaten. Foods should be cooked without fat and seasoned to taste. Avoid sauces, gravies, butter, margarine, mayonnaise and junk foods.
    • Never eat between meals. Do not drink flavored beverages, even diet soda, between meals.
    • Drink 2-3 quarts or more of water each day. Water must be consumed slowly, 1-2 mouthfuls at a time, due to the restrictive effect of the operation.
    • Exercise aerobically every day for at least 20 minutes (one-mile brisk walk, bike riding, stair climbing, etc.). Weight/resistance exercise can be added 3-4 days per week, as instructed by your doctor.
  • What's so important about exercise?
    When you have a weight loss surgery procedure, you lose weight because the amount of food energy (calories) you are able to eat is much less than your body needs to operate. It has to make up the difference by burning reserves or unused tissues. Your body will tend to burn any unused muscle before it begins to burn the fat it has saved up. If you do not exercise daily, your body will consume your unused muscle, and you will lose muscle mass and strength. Daily aerobic exercise for 20 minutes will communicate to your body that you want to use your muscles and force it to burn the fat instead.
  • What is the right amount of exercise after weight loss surgery?
    Many patients are hesitant about exercising after surgery, but exercise is an essential component of success after surgery. Exercise actually begins on the afternoon of surgery - the patient must be out of bed and walking. The goal is to walk further on the next day, and progressively further every day after that, including the first few weeks at home. Patients are often released from medical restrictions and encouraged to begin exercising about two weeks after surgery, limited only by the level of wound discomfort. The type of exercise is dictated by the patient's overall condition. Some patients who have severe knee problems can't walk well, but may be able to swim or bicycle. Many patients begin with low stress forms of exercise and are encouraged to progress to more vigorous activity when they are able.
  • Can I get pregnant after weight loss surgery?
    It is strongly recommended that women wait at least one year after the surgery before a pregnancy. Approximately one year post-operatively, your body will be fairly stable (from a weight and nutrition standpoint) and you should be able to carry a normally nourished fetus. You should consult your surgeon as you plan for pregnancy.
  • What if I have had a previous weight loss surgical procedure and I'm now having problems?
    Contact your original surgeon - he or she is most familiar with your medical history and can make recommendations based on knowledge of your surgical procedure and body.
  • What happens to the lower part of the stomach that is bypassed?
    In some surgical procedures, the stomach is left in place with intact blood supply. In some cases it may shrink a bit and its lining (the mucosa) may atrophy, but for the most part it remains unchanged. The lower stomach still contributes to the function of the intestines even though it does not receive or process food - it makes intrinsic factor, necessary to absorb Vitamin B12 and contributes to hormone balance and motility of the intestines in ways that are not entirely known. In the BPD procedures, some portion of the stomach is completely removed.
  • How big will my stomach pouch really be in the long run?
    This can vary by surgical procedure and surgeon. In the Roux-en-Y gastric bypass, the stomach pouch is created at one ounce or less in size (15-20cc). In the first few months it is rather stiff due to natural surgical inflammation. About 6-12 months after surgery, the stomach pouch can expand and will become more expandable as swelling subsides. Many patients end up with a meal capacity of 3-7 ounces.
  • What will the staples do inside my abdomen? Is it okay in the future to have an MRI test? Will I set off metal detectors in airports?
    The staples used on the stomach and the intestines are very tiny in comparison to the staples you will have in your skin or staples you use in the office. Each staple is a tiny piece of stainless steel or titanium so small it is hard to see other than as a tiny bright spot. Because the metals used (titanium or stainless steel) are inert in the body, most people are not allergic to staples and they usually do not cause any problems in the long run. The staple materials are also non-magnetic, which means that they will not be affected by MRI. The staples will not set off airport metal detectors.
  • What if I'm not hungry after surgery?
    It's normal not to have an appetite for the first month or two after weight loss surgery. If you are able to consume liquids reasonably well, there is a level of confidence that your appetite will increase with time.
  • Is there any difficulty in taking medications?
    Most pills or capsules are small enough to pass through the new stomach pouch. Initially, your doctor may suggest that medications be taken in liquid form or crushed.
  • Will I be able to take oral contraception after surgery?
    Most patients have no difficulty in swallowing these pills.
  • Is sexual activity restricted?
    Patients can return to normal sexual intimacy when wound healing and discomfort permit. Many patients experience a drop in desire for about 6 weeks.
  • Is there a difference in the outcome of surgery between men and women?
    Both men and women generally respond well to this surgery. In general, men lose weight slightly faster than women do.
  • Will I be asked to stop smoking?
    Patients are encouraged to stop smoking at least one month before surgery.
  • If I continue to smoke, what happens?
    Smoking increases the risk of lung problems after surgery, can reduce the rate of healing, increases the rates of infection, and interferes with blood supply to the healing tissues.
  • How can I know that I won't just keep losing weight until I waste away to nothing?
    Patients may begin to wonder about this early after the surgery when they are losing 20-40 pounds per month, or maybe when they've lost more than 100 pounds and they're still losing weight. Two things happen to allow weight to stabilize. First, a patient's ongoing metabolic needs (calories burned) decrease as the body sheds excess pounds. Second, there is a natural progressive increase in calorie and nutrient intake over the months following weight loss surgery. The stomach pouch and attached small intestine learn to work together better, and there is some expansion in pouch size over a period of months. The bottom line is that, in the absence of a surgical complication, patients are very unlikely to lose weight to the point of malnutrition.
  • What can I do to prevent lots of excess hanging skin?
    Many people heavy enough to meet the surgical criteria for weight loss surgery have stretched their skin beyond the point from which it can "snap back." Some patients will choose to have plastic surgery to remove loose or excess skin after they have lost their excess weight. Insurance generally does not pay for this type of surgery (often seen as elective surgery). However, some do pay for certain types of surgery to remove excess skin when complications arise from these excess skin folds. Ask your surgeon about your need for a skin removal procedure.
  • Will exercise help with excess hanging skin?
    Exercise is good in so many other ways that a regular exercise program is recommended. Unfortunately, most patients may still be left with large flaps of loose skin.
  • Will I be miserably hungry after weight loss surgery since I'm not eating much?
    Most patients say no. In fact, for the first 4-6 weeks patients have almost no appetite. Over the next several months the appetite returns, but it tends not to be a ravenous "eat everything in the cupboard" type of hunger.
  • What if I am really hungry?
    This is usually caused by the types of food you may be consuming, especially starches (rice, pasta, potatoes). Be absolutely sure not to drink liquid with food since liquid washes food out of the pouch.
  • Will I have to change my medications?
    Your doctor will determine whether medications for blood pressure, diabetes, etc., can be stopped when the conditions for which they are taken improve or resolve after weight loss surgery. For meds that need to be continued, the vast majority can be swallowed, absorbed and work the same as before weight loss surgery. Usually no change in dose is required. Two classes of medications that should be used only in consultation with your surgeon are diuretics (fluid pills) and NSAIDs (most over-the-counter pain medicines). NSAIDs (ibuprofen, naproxen, etc.) may create ulcers in the small pouch or the attached bowel. Most diuretic medicines make the kidneys lose potassium. With the dramatically reduced intake experienced by most weight loss surgery patients, they are not able to take in enough potassium from food to compensate. When potassium levels get too low, it can lead to fatal heart problems.
  • What is a hernia and what is the probability of an abdominal hernia after surgery?
    A hernia is a weakness in the muscle wall through which an organ (usually small bowel) can advance. Approximately 20% of patients develop a hernia. Most of these patients require a repair of the herniated tissue. The use of a reinforcing mesh to support the repair is common.
  • Is blood transfusion required?
    Infrequently: If needed, it is usually given after surgery to promote healing.
  • What is phlebitis and is it preventable?
    Undesired blood clotting in veins, especially of the calf and pelvis. It is not completely preventable, but preventive measures will be taken, including:
    1. Early ambulation
    2. Special stockings
    3. Blood thinners
    4. Pulsatile boots
  • Will I lose hair after surgery? How can I prevent it?
    Many patients experience some hair loss or thinning after surgery. This usually occurs between the fourth and the eighth month after surgery. Consistent intake of protein at mealtime is the most important prevention method. Also recommended are a daily zinc supplement and a good daily volume of fluid intake.
  • Does hair growth recover?
    Most patients experience natural hair regrowth after the initial period of loss.
  • What are adhesions and do they form after this surgery?
    Adhesions are scar tissues formed inside the abdomen after surgery or injury. Adhesions can form with any surgery in the abdomen. For most patients, these are not extensive enough to cause problems.
  • What is the "Candida Syndrome?"
    Some patients have a type of yeast present on the surface of their skin, intestine or vagina at the time of surgery. This leads to overgrowth in certain circumstances. A whitish coating may occur on the tongue or throat. This syndrome is associated with a frothy mucous, nausea, difficulty swallowing, sore throat, loss of taste and appetite, and occasionally abdominal bloating and diarrhea.
  • What causes it to appear?
    It is promoted by the use of most antibiotics and some other medications, by stress, by reduced immune response, and by diabetes.
  • Can it be cured?
    There are several effective medications now available for treating the overgrowth of Candida.
  • What is sleep apnea (SA)?
    It is the interruption of the normal sleep pattern associated with repeated delays in breathing. Sleep apnea often shows rapid improvement after surgery. In most patients, there is a complete resolution of symptoms by six months following surgery.
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Diet

  • How long will I be off of solid foods after surgery?
    Most surgeons recommend a period of four weeks or more without solid foods after surgery. A liquid diet, followed by semi-solid foods or pureed foods, may be recommended for a period of time until adequate healing has occurred. Your surgeon will provide you with specific dietary guidelines for the best post-surgical outcome.
  • What are the best choices of protein?
    Eggs, low-fat cheese, low-fat cottage cheese, tofu, fish, other seafood, chicken (dark meat), turkey (dark meat).
  • Why drink so much water?
    When you are losing weight, there are many waste products to eliminate, mostly in the urine. Some of these substances tend to form crystals, which can cause kidney stones. A high water intake protects you and helps your body to rid itself of waste products efficiently, promoting better weight loss. Water also fills your stomach and helps to prolong and intensify your sense of satisfaction with food. If you feel a desire to eat between meals, it may be because you did not drink enough water in the hour before.
  • What is Dumping Syndrome?
    Eating sugars or other foods containing many small particles when you have an empty stomach can cause dumping syndrome in patients who have had a gastric bypass or BPD where the stomach pylorus is removed. Your body handles these small particles by diluting them with water, which reduces blood volume and causes a shock-like state. Sugar may also induce insulin shock due to the altered physiology of your intestinal tract. The result is a very unpleasant feeling: you break out in a cold clammy sweat, turn pale, feel "butterflies" in your stomach, and have a pounding pulse. Cramps and diarrhea may follow. This state can last for 30-60 minutes and can be quite uncomfortable - you may have to lie down until it goes away. This syndrome can be avoided by not eating the foods that cause it, especially on an empty stomach. A small amount of sweets, such as fruit, can sometimes be well tolerated at the end of a meal.
  • Is there a problem with consuming milk products
    Milk contains lactose (milk sugar), which is not well digested. This sugar passes through undigested until bacteria in the lower bowel act on it, producing irritating byproducts as well as gas. Depending on individual tolerance, some persons find even the smallest amount of milk can cause cramps, gas and diarrhea.
  • Why can't I snack between meals?
    Snacking, nibbling or grazing on foods, usually high-calorie and high-fat foods, can add hundreds of calories a day to your intake, defeating the restrictive effect of your operation. Snacking will slow down your weight loss and can lead to regain of weight.
  • Why can't I eat red meat after surgery?
    You can, but you will need to be very careful, and we recommend that you avoid it for the first several months. Red meats contain a high level of meat fibers (gristle) which hold the piece of meat together, preventing you from separating it into small parts when you chew. The gristle can plug the outlet of your stomach pouch and prevent anything from passing through, a condition that is very uncomfortable.
  • How can I be sure I am eating enough protein?
    40 to 65 grams a day are generally sufficient. Check with your surgeon to determine the right amount for your type of surgery.
  • Is there any restriction of salt intake?
    No, your salt intake will be unchanged unless otherwise instructed by your primary care physician.
  • Will I be able to eat "spicy" foods or seasoned foods?
    Most patients are able to enjoy spices after the initial 6 months following surgery.
  • Will I be allowed to drink alcohol?
    You will find that even small amounts of alcohol will affect you quickly. It is suggested that you drink no alcohol for the first year. Thereafter, with your physician's approval, you may have a glass of wine or a small cocktail.
  • Will I need supplemental vitamins?
    B12 injections are sometimes suggested once a month for the first year and every six months thereafter. B12 may also be taken orally or sublingually (under the tongue) by many patients.
  • What vitamins will I need to take after surgery?
    Most surgeons recommend a daily multivitamin for the rest of your life.
  • Is it important to take calcium, iron, trace elements or female hormone replacements?
    Some patients require these supplements, but your need for these can be determined by your surgeon.
  • Do I meet with a nutritionist before and after surgery?
    Most surgeons require patients to consult with a nutritionist before surgery. Counseling after surgery is available on an individual basis as needed or required by your physician.
  • Will I get a copy of suggested eating patterns and food choices after surgery?
    Surgeons provide patients with materials that clearly outline their expectations regarding diet and compliance to guidelines for the best outcome based on your surgical procedure. After surgery, health and weight loss are highly dependent on patient compliance with these guidelines. You must do your part by restricting high-calorie foods, by avoiding sugar, snacks and fats, and by strictly following the guidelines set by your surgeon.
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General

  • What is the youngest age for which weight loss surgery is recommended?
    Generally accepted guidelines from the American Society for Bariatric Surgery and the National Institutes of Health indicate surgery only for those 18 years of age and older. Surgery has been performed on patients 16 and younger. There is a real concern that young patients may not have reached full developmental or emotional maturity to make this type of decision. It is important that young weight loss surgery patients have a full understanding of the lifelong commitment to the altered eating and lifestyle changes necessary for success.
  • What is the oldest patient for whom weight loss surgery is recommended?
    Patients over 65 require very strong indications for surgery and must also meet stringent Medicare criteria. The risk of surgery in this age group is increased, and the benefits, in terms of reduced risk of mortality, are reduced.
  • Can Weight Loss Surgery prolong my life?
    There is good evidence from scientific research that if you have Type 2 diabetes (or other serious obesity-related health conditions), are at least 100 lbs. over ideal body weight, and are able to comply with lifestyle changes (daily exercise and low-fat diet), then weight loss surgery may significantly prolong your life.
  • Can weight loss surgery help other physical conditions?
    According to current research, weight loss surgery can improve or resolve associated health conditions.
Condition Percentage found in preoperative individuals Percentage cured 2 years after surgery
Diabetes or insulin resistance 34% 85%
High blood pressure 26% 66%
High triglycerides 40% 85%
Sleep apnea 22% in males, 1% in females 40%

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Options for Treatment

For anyone who has considered a weight loss program, there is certainly no shortage of choices. In fact, to qualify for insurance coverage of weight loss surgery, many insurers require patients to have a history of medically supervised weight loss efforts.

Most non-surgical weight loss programs are based on some combination of diet/behavior modification and regular exercise. Unfortunately, even the most effective interventions have proven to be effective for only a small percentage of patients. It is estimated that less than 5% of individuals who participate in non-surgical weight loss programs will lose a significant amount of weight and maintain that loss for a long period of time.

According to the National Institutes of Health, more than 90% of all people in these programs regain their weight within one year. Sustained weight loss for patients who are morbidly obese is even harder to achieve. Serious health risks have been identified for people who move from diet to diet, subjecting their bodies to a severe and continuing cycle of weight loss and gain known as "yo-yo dieting."

The fact remains that morbid obesity is a complex, multifactorial chronic disease.

For many patients, the risk of death from not having the surgery is greater than the risks from the possible complications of having the procedure.

That is the key reason that in 2000, approximately 40,000 weight loss surgical procedures were performed and why the American Society for Bariatric Surgery estimates that 50,000 weight loss surgical procedures will be performed in 2001. Patients who have had the procedure and are benefiting from its results report improvements in their quality of life, social interactions, psychological well-being, employment opportunities and economic condition.

In clinical studies, candidates for the procedure who had multiple obesity-related health conditions questioned whether they could safely have the surgery. These studies show that selection of surgical candidates is based on very strict criteria and surgery is an option for the majority of patients.



 

Weight Loss Surgery

Weight loss surgery is major surgery. Its growing use to treat morbid obesity is the result of three factors:

  • Our current knowledge of the significant health risks of morbid obesity
  • The relatively low risk and complications of the procedures versus not having the surgery
  • The ineffectiveness of current non-surgical approaches to produce sustained weight loss

Surgery should be viewed first and foremost as a method for alleviating debilitating, chronic disease. In most cases, the minimum qualification for consideration as a candidate for the procedure is 100 lbs. above ideal body weight or those with a Body Mass Index of 40 or greater. Occasionally a procedure will be considered for someone with a BMI of 35 or higher if the patient's physician determines that obesity-related health conditions have resulted in a medical need for weight reduction and, in the doctor's opinion, surgery appears to be the only way to accomplish the targeted weight loss. In many cases, patients are required to show proof that their attempts at dietary weight loss have been ineffective before surgery will be approved. More important, however, is the commitment on the part of the patient to required, long-term follow-up care. Most surgeons require patients to demonstrate serious motivation and a clear understanding of the extensive dietary, exercise and medical guidelines that must be followed for the remainder of their lives after having weight loss surgery (see Life After Surgery).

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Diet & Behavior Modification

There are literally hundreds of diets available. Moving from diet to diet in a cycle of weight gain and loss - yo-yo dieting - that stresses the heart, kidneys and other organs can also be a health risk.

Doctors who prescribe and supervise diets for their patients usually create a customized program with the goal of greatly restricting calorie intake while maintaining nutrition.
These diets fall into two basic categories:

  • Low Calorie Diets (LCDs) are individually planned so that the patient takes in 500 to 1,000 fewer calories a day than he or she burns.
  • Very Low Calorie Diets (VLCDs) typically limit caloric intake to 400 to 800 a day and feature high-protein, low-fat liquids.

Many patients on Very Low Calorie Diets lose significant amounts of weight. However, after returning to a normal diet, most regain the lost weight in under a year. Ninety percent of people participating in all diet programs will regain the weight they've lost within two years.

Behavior modification uses therapy to help patients change their eating and exercise habits. Like low-calorie diets, behavior modification, in most patients, results in short-term success that tends to diminish after the first year.

If diet and behavior modifications have failed you and surgery is your next option, it is important to understand that diet and behavior modification will be instrumental to sustained weight loss after your surgery. The surgery itself is only a tool to get your body started losing weight - complying with diet and behavior modifications required by most surgeons would determine your ultimate success.

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Exercise

Starting an exercise program can be especially intimidating for someone suffering from morbid obesity. Your health condition may make any level of physical exertion next to impossible. The benefits of exercise are clear, however. And there are ways to get started.

A National Institutes of Health survey of 13 studies concludes that physical activity:

  • results in modest weight loss in overweight and obese individuals
  • increases cardiovascular fitness, even when there is no weight loss
  • can help maintain weight loss

New theories focusing on the body's set point (the weight range in which your body is programmed to weigh and will fight to maintain that weight) highlight the importance of exercise. When you reduce the number of calories you take in, the body simply reacts by slowing metabolism to burn fewer calories. Daily physical activity can help speed up your metabolism, effectively bringing your set point down to a lower natural weight. So when following a diet to attempt to lose weight, exercise increases your chances of long-term success.

Examples to get you started:

  • Park at the far end of parking lots and walk
  • Take the stairs instead of the elevator
  • Cut down on television
  • Swim or participate in low-impact water aerobics
  • Ride an exercise bike

Overall, walking is one of the best forms of exercise. Start out slowly and build up. Your doctor, or people in a support group, can offer encouragement and advice. Incorporating exercise into your daily activities will improve your overall health and is important for any long-term weight management program, including weight loss surgery. Diet and exercise play a key role in successful weight loss after surgery.

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Over-the-Counter & Prescription Drugs

New over-the-counter and prescription weight loss medications have been introduced. Some people have found them effective in helping to curb their appetite. The results of most studies show that patients on drug therapy lose around 10 percent of their excess weight and that the weight loss plateaus after six to eight months. As patients stop taking the medication, weight gain usually occurs.

Weight loss drugs can have serious side effects. Still, medications are an important step in the morbid obesity treatment process. Before insurance companies will reimburse/pay for weight loss surgery, you must follow a well-documented treatment path.

"Since many people cannot lose much weight no matter how hard they try, and promptly regain whatever they do lose, the vast amount of money spent on diet clubs, special foods and over-the-counter remedies, estimated to be on the order of $30 billion to $50 billion yearly, is wasted." (New England Journal of Medicine)

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How Surgery Reduces Weight

Surgeons first began to recognize the potential for surgical weight loss while performing operations that required the removal of large segments of a patient's stomach and intestine. After the surgery, doctors noticed that in many cases patients were unable to maintain their pre-surgical weight. With further study, surgeons were able to recommend similar modifications that could be safely used to produce weight loss in morbidly obese patients. Over the last decade these procedures have been continually refined in order to improve results and minimize risks. Today's bariatric surgeons have access to a substantial body of clinical data to help them determine which surgeries should be used and why.

Today, the American Society for Bariatric Surgery describes two basic approaches that weight loss surgery takes to achieve change:

  1. Restrictive procedures that decrease food intake.
  2. Malabsorptive procedures that alter digestion, thus causing the food to be poorly digested and incompletely absorbed so that it is eliminated in the stool.



 

Restrictive Procedures

The theory is simple. When you feel full, you are more likely to have reduced feelings of hunger and will no longer feel deprived. The result is that you are likely to eat less. Restrictive weight loss surgery works by reducing the amount of food consumed at one time. It does not, however, interfere with the normal absorption (digestion) of food. In a restrictive procedure, the surgeon creates a smaller upper stomach pouch. The pouch, with a capacity of approximately 1/2 to 1 oz. (15 to 30 ml), connects to the rest of the stomach through an outlet known as a "stoma." In a cooperative and compliant patient, the reduced stomach capacity, along with behavioral changes, can result in consistently lower caloric intake and consistent weight loss.

During recovery, patients must adhere to the strict specific dietary guidelines and restrictions their surgeon prescribes. While these guidelines may vary from one surgeon to the next, it is important for each patient to follow the surgeon's guidelines. When the time comes to resume eating "regular" food, the patient must learn to adapt to a new way of eating. At each meal, they are restricted to consuming approximately 1/2 to a full cup of food before feeling uncomfortably full. Patients who see the best results from a restrictive procedure are those who learn to eat slowly, eat less, and avoid drinking too many fluids, particularly carbonated beverages. If the patient fails to follow these guidelines, they can stretch the stomach pouch and/or the stoma outlet and defeat the purpose of the surgery. The effectiveness of a restrictive procedure is reduced by constant snacking or by drinking high-calorie, high-fat liquids. Failure to achieve the expected level of weight loss is usually the result of a patient failing to comply with the recommended dietary and behavior modifications, such as increased exercise and regular support group attendance.

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Malabsorptive Procedures that Alter Digestion

It can be said that some of the restrictive approaches discussed above have not always achieved the excess weight loss surgeons and patients anticipated. For this reason, procedures that alter digestion, known as malabsorptive procedures, were developed to work in conjunction with restrictive approaches. Some of these techniques involve a bypass of the small intestine, thus limiting the absorption of calories. On balance, malabsorptive or malabsorptive/restrictive procedures have resulted in an overall increase in the loss of excess weight. The risk of complications and side effects generally increases with the lengthening of the small intestine bypass. You and your surgeon must determine the risks and benefits over your lifetime with the type of weight loss surgery you choose.

Basically, weight loss operations fall into three categories:

  • Restrictive procedures make the stomach smaller to limit the amount of food intake.
  • Malabsorptive techniques reduce the amount of intestine that comes in contact with food so that the body absorbs fewer calories.
  • Combination operations take advantage of both restriction and malabsorption.

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The Gastrointestinal Tract

To better understand how weight loss surgery works, it is important to understand how your gastrointestinal tract functions. As the food you consume moves through the tract, various digestive juices and enzymes are introduced at specific stages that allow absorption of nutrients. Food material that is not absorbed is then prepared for elimination. A simplified description of the gastrointestinal tract appears below. Your doctor can provide a more detailed description to help you better understand how weight loss surgery works.

  1. The esophagus is a long muscular tube, which moves food from the mouth to the stomach.
  2. The abdomen contains all of the digestive organs.
  3. The stomach, situated at the top of the abdomen, normally holds just over 3 pints (about 1500 ml) of food from a single meal. Here the food is mixed with an acid that is produced to assist in digestion. In the stomach, acid and other digestive juices are added to the ingested food to facilitate breakdown of complex proteins, fats and carbohydrates into small, more absorbable units.
  4. A valve at the entrance to the stomach from the esophagus allows the food to enter while keeping the acid-laden food from "refluxing" back into the esophagus, causing damage and pain.
  5. The pylorus is a small round muscle located at the outlet of the stomach and the entrance to the duodenum (the first section of the small intestine). It closes the stomach outlet while food is being digested into a smaller, more easily absorbed form. When food is properly digested, the pylorus opens and allows the contents of the stomach into the duodenum.
  6. The small intestine is about 15 to 20 feet long (4.5 to 6 meters) and is where the majority of the absorption of the nutrients from food takes place. The small intestine is made up of three sections: the duodenum, the jejunum and the ileum.
  7. The duodenum is the first section of the small intestine and is where the food is mixed with bile produced by the liver and with other juices from the pancreas. This is where much of the iron and calcium is absorbed.
  8. The jejunum is the middle part of the small intestine extending from the duodenum to the ileum; it is responsible for digestion.
  9. The last segment of the intestine, the ileum, is where the absorption of fat-soluble vitamins A, D, E and K and other nutrients are absorbed.
  10. Another valve separates the small and large intestines to keep bacteria-laden colon contents from coming back into the small intestine.
  11. In the large intestines, excess fluids are absorbed and a firm stool is formed. The colon may absorb protein, when necessary.

Weight Loss Surgery Procedures - Which Is Right For You?

The most important step in weight loss surgery is getting all of the information you need about the various surgical options. Ultimately your surgeon and other physicians are your best resource for information about the procedure they will recommend to you. When you ask a question, make sure you understand the answer. Do not hesitate to ask for a clearer explanation given in simpler language. The decision to have a weight loss surgical procedure may take several visits to their office and consultation with more than one doctor. Ask your doctor for names of other patients who have had similar procedures and who are willing to discuss their experiences, good and bad, with you.

You may choose to research weight loss surgery on your own via the Internet or through your local library. As with any search for medical information, be sure that your sources are responsible recognized experts in the field you are investigating. An excellent resource for weight loss surgery is the American Society for Bariatric Surgery.

Although the results of weight loss surgery can be drastic, there are potential risks and complications. Before making your decision, you should be well informed. These steps are necessary if you are to give what is called "informed consent" for the procedure. Informed consent is a legal term meaning that a patient agrees that they have received and understood enough information about a procedure's benefits and risks to allow them to make a decision that is right for them. Your surgeon will require you to sign a consent form before performing your procedure. Before you sign a consent form, you should have a solid understanding of what is about to take place. You should know what you would need to do to live well after the operation. And you should be aware of the signs or symptoms of complications to look for which may occur after your surgery.

Weight Loss Surgery Options

The American Society for Bariatric Surgery describes two basic approaches that weight loss surgery takes to achieve change:

  1. Restrictive procedures that decrease food intake.
  2. Malabsorptive procedures that alter digestion, thus causing the food to be poorly digested and incompletely absorbed so that it is eliminated in the stool.



 

Gastric Restrictive Procedure - Vertical Banded Gastroplasty

Vertical Banded Gastroplasty (VBG) is a purely restrictive procedure. In this procedure the upper stomach near the esophagus is stapled vertically for about 2-1/2 inches (6 cm) to create a smaller stomach pouch. The outlet from the pouch is restricted by a band or ring that slows the emptying of the food and thus creates the feeling of fullness.

Advantages

  • The primary advantage of this restrictive procedure is that a reduced amount of well-chewed food enters and passes through the digestive tract in the usual order. That allows the nutrients and vitamins (as well as the calories) to be fully absorbed into the body.
  • After 10 years, studies show that patients can maintain 50% of targeted excess weight loss.

Risks

  • Postoperatively, stapling of the stomach carries with it the risk of staple-line disruption that can result in leakage and/or serious infection. This may require prolonged hospitalization with antibiotic treatment and/or additional operations.
  • Staple-line disruption may also, in the long-term, lead to weight gain. For these reasons, some surgeons divide the staple-line wall of the pouch from the rest of the stomach to reduce the risk of long-term staple-line disruption.
  • The band or ring applied may lead to complications of obstruction or perforation, requiring surgical intervention.
  • Characteristically, these procedures, while creating a sense of fullness, do not provide the necessary feeling of satisfaction that one has had "enough" to eat.
  • Because restrictive procedures rely solely on a small stomach pouch to reduce food intake, there is the risk of the pouch stretching or of the restricting band or ring at the pouch outlet breaking or migrating, thus allowing patients to eat too much.
  • Around 40% of patients undergoing these procedures have lost less than half their excess body weight.
  • As is the case with all weight loss surgeries, readmission to a hospital may be required for fluid replacement or nutritional support if there is excessive vomiting and adequate food intake cannot be maintained.

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Malabsorptive Procedures - Biliopancreatic Diversion

While these operations also reduce the size of the stomach, the stomach pouch created is much larger than with other procedures. The goal is to restrict the amount of food consumed and alter the normal digestive process, but to a much greater degree. The anatomy of the small intestine is changed to divert the bile and pancreatic juices so they meet the ingested food closer to the middle or the end of the small intestine.With the three approaches discussed below, absorption of nutrients and calories is also reduced, but to a much greater degree than with previously discussed procedures. Each of the three differs in how and when the digestive juices (i.e., bile) come into contact with the food.

Since food bypasses the duodenum, all the risk considerations discussed in the gastric bypass section regarding the malabsorption of some minerals and vitamins also apply to these techniques, only to a greater degree.

Biliopancreatic Diversion (BPD) BPD removes approximately 3/4 of the stomach to produce both restriction of food intake and reduction of acid output. Leaving enough upper stomach is important to maintain proper nutrition. The small intestine is then divided with one end attached to the stomach pouch to create what is called an "alimentary limb." All the food moves through this segment, however, not much is absorbed. The bile and pancreatic juices move through the "biliopancreatic limb," which is connected to the side of the intestine close to the end. This supplies digestive juices in the section of the intestine now called the "common limb." The surgeon is able to vary the length of the common limb to regulate the amount of absorption of protein, fat and fat-soluble vitamins.

Extended (Distal) Roux-en-Y Gastric Bypass (RYGBP-E) RYGBP-E is an alternative means of achieving malabsorption by creating a stapled or divided small gastric pouch, leaving the remainder of stomach in place. A long limb of the small intestine is attached to the stomach to divert the bile and pancreatic juices. This procedure carries with it fewer operative risks by avoiding removal of the lower 3/4 of the stomach. Gastric pouch size and the length of the bypassed intestine determine the risks for ulcers, malnutrition and other effects.

Biliopancreatic Diversion with "Duodenal Switch" This procedure is a variation of BPD in which stomach removal is restricted to the outer margin, leaving a sleeve of stomach with the pylorus and the beginning of the duodenum at its end. The duodenum, the first portion of the small intestine, is divided so that pancreatic and bile drainage is bypassed. The near end of the "alimentary limb" is then attached to the beginning of the duodenum, while the "common limb" is created in the same way as described above.

Advantages

  1. These operations often result in a high degree of patient satisfaction because patients are able to eat larger meals than with a purely restrictive or standard Roux-en-Y gastric bypass procedure.
  2. These procedures can produce the greatest excess weight loss because they provide the highest levels of malabsorption.
  3. In one study of 125 patients, excess weight loss of 74% at one year, 78% at two years, 81% at three years, 84% at four years, and 91% at five years was achieved.
  4. Long-term maintenance of excess body weight loss can be successful if the patient adapts and adheres to a straightforward dietary, supplement, exercise and behavioral regimen.

Risks

  1. For all malabsorption procedures there is a period of intestinal adaptation when bowel movements can be very liquid and frequent. This condition may lessen over time, but may be a permanent lifelong occurrence.
  2. Abdominal bloating and malodorous stool or gas may occur.
  3. Close lifelong monitoring for protein malnutrition, anemia and bone disease is recommended. As well, lifelong vitamin supplementing is required. It has been generally observed that if eating and vitamin supplement instructions are not rigorously followed, at least 25% of patients will develop problems that require treatment.
  4. Changes to the intestinal structure can result in the increased risk of gallstone formation and the need for removal of the gallbladder.
  5. Re-routing of bile, pancreatic and other digestive juices beyond the stomach can cause intestinal irritation and ulcers.

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Combined Restrictive & Malabsorptive Procedure - Gastric Bypass Roux-en-Y

In recent years, better clinical understanding of procedures combining restrictive and malabsorptive approaches has increased the choices of effective weight loss surgery for thousands of patients. By adding malabsorption, food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients. The result is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat.

According to the American Society for Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. It is one of the most frequently performed weight loss procedures in the United States. In this procedure, stapling creates a small (15 to 20cc) stomach pouch. The remainder of the stomach is not removed, but is completely stapled shut and divided from the stomach pouch. The outlet from this newly formed pouch empties directly into the lower portion of the jejunum, thus bypassing calorie absorption. This is done by dividing the small intestine just beyond the duodenum for the purpose of bringing it up and constructing a connection with the newly formed stomach pouch. The other end is connected into the side of the Roux limb of the intestine creating the "Y" shape that gives the technique its name. The length of either segment of the intestine can be increased to produce lower or higher levels of malabsorption.

Advantages

  • The average excess weight loss after the Roux-en-Y procedure is generally higher in a compliant patient than with purely restrictive procedures.
  • One year after surgery, weight loss can average 77% of excess body weight.
  • Studies show that after 10 to 14 years, 50-60% of excess body weight loss has been maintained by some patients.
  • A 2000 study of 500 patients showed that 96% of certain associated health conditions studied (back pain, sleep apnea, high blood pressure, diabetes and depression) were improved or resolved.

Risks

  • Because the duodenum is bypassed, poor absorption of iron and calcium can result in the lowering of total body iron and a predisposition to iron deficiency anemia. This is a particular concern for patients who experience chronic blood loss during excessive menstrual flow or bleeding hemorrhoids. Women, already at risk for osteoporosis that can occur after menopause, should be aware of the potential for heightened bone calcium loss.
  • Bypassing the duodenum has caused metabolic bone disease in some patients, resulting in bone pain, loss of height, humped back and fractures of the ribs and hip bones. All of the deficiencies mentioned above, however, can be managed through proper diet and vitamin supplements.
  • A chronic anemia due to Vitamin B12 deficiency may occur. The problem can usually be managed with Vitamin B12 pills or injections.
  • A condition known as "dumping syndrome " can occur as the result of rapid emptying of stomach contents into the small intestine. This is sometimes triggered when too much sugar or large amounts of food are consumed. While generally not considered to be a serious risk to your health, the results can be extremely unpleasant and can include nausea, weakness, sweating, faintness and, on occasion, diarrhea after eating. Some patients are unable to eat any form of sweets after surgery.
  • In some cases, the effectiveness of the procedure may be reduced if the stomach pouch is stretched and/or if it is initially left larger than 15-30cc.
  • The bypassed portion of the stomach, duodenum and segments of the small intestine cannot be easily visualized using X-ray or endoscopy if problems such as ulcers, bleeding or malignancy should occur.

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Laparoscopic or Minimally Invasive Surgery

For the last decade, laparoscopic procedures have been used in a variety of general surgeries. Many people mistakenly believe that these techniques are still "experimental." In fact, laparoscopy has become the predominant technique in some areas of surgery and has been used for weight loss surgery for several years. Although few bariatric surgeons perform laparoscopic weight loss surgeries, more are offering patients this less invasive surgical option whenever possible.

When a laparoscopic operation is performed, a small video camera is inserted into the abdomen. The surgeon views the procedure on a separate video monitor. Most laparoscopic surgeons believe this gives them better visualization and access to key anatomical structures.

The camera and surgical instruments are inserted through small incisions made in the abdominal wall. This approach is considered less invasive because it replaces the need for one long incision to open the abdomen. A recent study shows that patients having had laparoscopic weight loss surgery experience less pain after surgery resulting in easier breathing and lung function and higher overall oxygen levels. Other realized benefits with laparoscopy have been fewer wound complications such as infection or hernia, and patients returning more quickly to pre-surgical levels of activity.

Laparoscopic procedures for weight loss surgery employ the same principles as their "open" counterparts and produce similar excess weight loss. Not all patients are candidates for this approach, just as all bariatric surgeons are not trained in the advanced techniques required to perform this less invasive method. The American Society for Bariatric Surgery recommends that laparoscopic weight loss surgery should only be performed by surgeons who are experienced in both laparoscopic and open bariatric procedures.

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How Effective Is Surgery?

The actual weight a patient will lose after the procedure is dependent on several factors. These include:

  • Patient's age
  • Weight before surgery
  • Overall condition of patient's health
  • Surgical procedure
  • Ability to exercise
  • Commitment to maintaining dietary guidelines and other follow-up care
  • Motivation of patient and cooperation of their family, friends and associates

Man and woman

In general, weight loss surgery success is defined as achieving loss of 50% or more of excess body weight and maintaining that level for at least five years. Clinical data will vary for each of the different procedures mentioned on this site. Results may also vary by surgeon. Ask your doctor for the clinical data stating their results of the procedure they are recommending.

Family

Clinical studies show that, following surgery, most patients lose weight rapidly and continue to do so until 18 to 24 months after the procedure. Patients may lose 30 to 50% of their excess weight in the first six months and 77% of excess weight as early as 12 months after surgery. Another study showed that patients can maintain a 50-60% loss of excess weight 10-14 years after surgery. Patients with higher initial BMIs tend to lose more total weight. Patients with lower initial BMIs will lose a greater percentage of their excess weight and will more likely come closer to their ideal body weight. Patients with Type 2 Diabetes tend to show less overall excess weight loss than patients without Type 2 Diabetes. The surgery has been found to be effective in improving and controlling many obesity-related health conditions. A 2000 study of 500 patients showed that 96% of certain associated health conditions studied (back pain, sleep apnea, high blood pressure, diabetes and depression) were improved or resolved. For example, many patients with Type 2 Diabetes, while showing less overall excess weight loss, have demonstrated excellent resolution of their diabetic condition, to the point of having little or no need for continuing medication.

Risks and Complications of Bariatric Surgery

Surgery should not be considered until you and your doctor have evaluated all other options. As with all surgeries, there are risks associated with this procedure. If complications occur during the operation, your doctor may choose to perform open surgery. Your doctor must determine if you are an appropriate surgical candidate.

Indication
Weight loss surgery is typically reserved for those individuals 100 pounds or more overweight (Body Mass Index [BMI] of 40 or higher) who have not responded to other less invasive therapies such as diet, exercise, medications, etc.

In certain circumstances, less morbidly obese patients (with BMIs between 35 and 40) may be considered for surgery (patients with high-risk co-morbid conditions and obesity-induced physical problems that are interfering with quality of life).

Important Considerations
Surgery should not be considered until you and your doctor have evaluated all other options. The proper approach to weight-loss surgery requires discussion and careful consideration of the following with your doctor:

  1. These procedures are in no way to be considered as cosmetic surgery.
  2. The surgery does not involve the removal of adipose tissue (fat) by suction or excision.
  3. A decision to elect surgical treatment requires an assessment of the risk and benefit to the patient and the meticulous performance of the appropriate surgical procedure.
  4. These weight loss surgical procedures (approved in the United States) are not reversible.
  5. The success of weight loss surgery is dependent upon long-term lifestyle changes in diet and exercise.
  6. Problems may arise after surgery that may require reoperations.

Success of surgical treatment must begin with realistic goals and progress through the best possible use of well-designed and tested operations.

Complications and Risks
As with any surgery, there are operative and long-term complications and risks associated with weight loss surgical procedures that should be discussed with your doctor. Possible risks include, but are not limited to:

  • Bleeding*
  • Complications due to anesthesia and medications
  • Deep vein thrombosis
  • Dehiscence
  • Infections
  • Leaks from staple line breakdown
  • Marginal ulcers
  • Pulmonary problems
  • Spleen injury*
  • Stenosis

*Removal of the spleen is necessary in about 0.3% of patients to control operative bleeding.

If surgery is performed laparoscopically and complications occur during the operation, your doctor may choose to perform open surgery.

Where to Begin

This web site is a good place to start. It has been created to give you a thorough understanding of the risks and benefits of this procedure. Talking to your primary care physician, physician specialist or family physician is a good next step. Finding a local weight loss surgeon and support group is another good step. Chances are there is a bariatric or weight loss clinic in or near your community that specializes in weight loss surgery. Call them to see if they offer seminars or free information sessions for the public.

You can also order a patient information kit about weight loss surgery by visiting our Free Information page. Remember, there is much misinformation about weight loss surgery that you may encounter from unqualified sources. Talking to others who have taken the path you are now considering may help you understand what you need to know to make a decision you can be comfortable with. In the end, your best source of information is an experienced bariatric surgeon who knows how to handle your special needs before, during and after weight loss surgery.

Choosing Surgery

Weight loss surgery is major surgery. Although most patients enjoy an improvement in obesity-related health conditions (such as mobility, self-image and self-esteem) after the successful results of weight loss surgery, these results should not be the overriding motivation for having the procedure.
The goal is to live better, healthier and longer.

That is why you should make the decision to have weight loss surgery only after careful consideration and consultation with an experienced bariatric surgeon or a knowledgeable family physician. A qualified surgeon should answer your questions clearly and explain the exact details of the procedure, the extent of the recovery period and the reality of the follow-up care that will be required. They may, as part of routine evaluation for weight loss surgery, require that you consult with a dietician/nutritionist and a psychiatrist/therapist. This is to help establish a clear understanding of the post-operative changes in behavior that are essential for long-term success.

It is important to remember that there are no ironclad guarantees in any kind of medicine or surgery. There can be unexpected outcomes in even the simplest procedures. What can be said, however, is that weight loss surgery will only succeed when the patient makes a lifelong commitment. Some of the challenges facing a person after weight loss surgery can be unexpected. Lifestyle changes can strain relationships within families and between married couples. To help patients achieve their goals and deal with the changes surgery and weight loss can bring, most bariatric surgeons offer follow-up care that includes support groups, dieticians and other forms of continuing education.

Ultimately, the decision to have the procedure is entirely up to you. After having heard all the information, you must decide if the benefits outweigh the side effects and potential complications. This surgery is only a tool. Your ultimate success depends on strict adherence to the recommended dietary, exercise and lifestyle changes.

The Importance of Support

The changes in your diet and lifestyle after surgery will last a lifetime. And you'll have a greater chance of long-term success if you surround yourself with people who understand and support your goals.

Things you can do:

  • Help your friends and family members understand why you've chosen a surgical solution. Many people are under the impression that weight loss surgery is an experimental treatment rather than one with more than 40 years of history. Direct them to this web site or others in our Additional Resources section. It's important that they understand that morbid obesity is a disease and that diets don't work for you.
  • People who are morbidly obese often report that their spouses, or others close to them, seem to discourage weight loss. These people see your weight as part of your identity. Understand that this is a fear of change. Discuss your reasons for having surgery. They need to know that your health is at stake and you will be counting on them to help you during and after surgery.
  • Attend support groups in your area or visit them online. Your surgeon's office will help you here. Surround yourself with people who share your situation. Ask questions and receive answers in a supportive environment. Form a network to share recipes and exercise tips. It's important for you to know that you are not alone. There are knowledgeable, friendly people available to support and help you.

Preparation for Surgery

Weight loss surgery is like other major surgeries. The best preparation is to understand the risks and potential benefits and to closely follow your doctor's instructions. To mentally prepare yourself:

  • Understand the surgical process and what to expect afterwards.
  • Talk to people who have had weight loss surgery.
  • Write a letter to yourself and your surgeon explaining your reasons for having the surgery and outlining your plans to maintain your weight loss after surgery.
  • Start a journal about your experience. Record how you feel now, the obstacles you encounter, the things you hope to be able to do after surgery.
  • Get a letter of support from your family. It helps to know you have people behind you, waiting to help.

To physically prepare yourself, strictly follow your doctor's guidelines. These usually include, but are not limited to:

  • Restricting yourself to a clear liquid diet 12-24 hours before surgery.
  • Stop smoking for at least a month before surgery.
  • Be certain to follow your surgeon's instructions regarding any medications you may be taking to control other health conditions.
  • Arrive on time, with supplies from home for a three- to four-day hospital stay. If you use special equipment for sleep apnea, you should bring your machine to the hospital.

The Hospital Stay

Most patients stay in the hospital approximately five to eight days after an open procedure and two to five days after a laparoscopic procedure. You will be discharged when you are able to:

  1. Take enough liquids and nutrients by mouth to prevent dehydration
  2. Have no fever
  3. Have adequate pain control with medication

Depending on which procedure is performed, one or two small tubes may be placed around the stomach pouch and the bypassed stomach to drain body fluids after the surgery. These are usually removed in three to ten days. To help prevent blood clots, anti-embolism stockings or other compression devices will be placed on your legs, and your surgeon will require you to attempt to stand up and move around as soon as possible, usually within the first 24 hours.

Depending on your medical condition, there is the possibility of being placed in the intensive care unit to closely monitor your heart and lungs. Depending on the hospital, patients who use Continuous Positive Airway Pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP) for sleep apnea may be asked to bring their machines with them for use immediately after the operation.

Life After Surgery

The following identifies areas that will be important for patients to follow after weight loss surgery.


 

Diet

The modifications made to your gastrointestinal tract will require permanent changes in your eating habits that must be adhered to for successful weight loss. Post-surgery dietary guidelines will vary by surgeon. You may hear of other patients who are given different guidelines following their weight loss surgery. It is important to remember that every surgeon does not perform the exact same weight loss surgery procedure and that the dietary guidelines will be different for each surgeon and each type of procedure. What is most important is that you adhere strictly to your surgeon's recommended guidelines. The following are some of the generally accepted dietary guidelines a weight loss surgery patient may encounter:

  • When you start eating solid food it is essential that you chew thoroughly. You will not be able to eat steaks or other chunks of meat if they are not ground or chewed thoroughly.
  • Don't drink fluids while eating. They will make you feel full before you have consumed enough food.
  • Omit desserts and other items with sugar listed as one of the first three ingredients.
  • Omit carbonated drinks, high-calorie nutritional supplements, milk shakes, high-fat foods and foods with high fiber content.
  • Avoid alcohol.
  • Limit snacking between meals.

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Going Back to Work

Your ability to resume pre-surgery levels of activity will vary according to your physical condition, the nature of the activity and the type of weight loss surgery you had. Many patients return to full pre-surgery levels of activity within six weeks of their procedure. Patients who have had a minimally invasive laparoscopic procedure may be able to return to these activities within a few weeks.

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Birth Control & Pregnancy

It is strongly advised that women of childbearing age use the most effective forms of birth control during the first 16 to 24 months after weight loss surgery. The added demands pregnancy places on your body and the potential for fetal damage make this a most important requirement.

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Long-Term Follow-Up

Although the short-term effects of weight loss surgery are well understood, there are still questions to be answered about the long-term effects on nutrition and body systems. Nutritional deficiencies that occur over the course of many years will need to be studied. Over time, you will need periodic checks for anemia (low red blood cell count) and Vitamin B12, folate and iron levels. Follow-up tests will initially be conducted every three to six months or as needed, and then every one to two years.

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Support Groups

The widespread use of support groups has provided weight loss surgery patients an excellent opportunity to discuss their various personal and professional issues. Most learn, for example, that weight loss surgery will not immediately resolve existing emotional issues or heal the years of damage that morbid obesity might have inflicted on their emotional well-being. Most surgeons have support groups in place to assist you with short-term and long-term questions and needs. Most bariatric surgeons who frequently perform weight loss surgery will tell you that ongoing post-surgical support helps produce the greatest level of success for their patients.

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