Bariatric Surgery

*Bariatric surgery is a safe and effective treatment option for those affected by severe obesity. Moreover, these same procedures have also been recognized for their impact on metabolic or hormonal changes that play a major role in hunger (the desire to start eating) and satiety (the desire to stop eating) as well as improvement and/or resolution of conditions that can occur as a result of severe obesity. Bariatric surgery is a recognized and accepted approach for both weight-loss and many of the conditions that occur as a result of severe obesity; however, not all people affected by severe obesity will qualify for bariatric surgery. There are certain criteria that a person must meet in order to be a candidate for bariatric surgery.

*Please Note: It is important to note that there are risks involved with bariatric surgery, as well as any other surgical procedure. Before making a treatment decision, it is important to discuss these risks with your primary care provider and/or surgeon. The OAC also encourages individuals to discuss these risks with their family members.

Indications:
At the 1991 National Institutes of Health (NIH) Consensus Conference, bariatric surgery was considered an accepted and effective approach that provides consistent, durable weight-loss for individuals affected by severe obesity. Furthermore, the NIH identified several criteria for candidacy for bariatric surgery, including:

      • No endocrine causes of obesity
      • Acceptable operative risk
      • Understands surgery and risks
      • Absence of drug or alcohol problem
      • No uncontrolled psychological conditions
      • Failed attempts at medical weight-loss (diets, other weight-loss options)
      • Body Mass Index (BMI) = a number calculated based on a person’s height and weight:
      • BMI >40, Severe obesity (or weighing more than 100 pounds over ideal body weight)
      • BMI 35-40 with significant obesity-related conditions (type 2 diabetes, high blood pressure, sleep apnea or high cholesterol)

Consult with your primary care provider (PCP) and insurance provider to see if you are a candidate.

Benefits:
Within two to three years after the operation, bariatric surgery usually results in a weight-loss of 40 to 80 percent of excess weight, depending on the chosen procedure. Those considering bariatric surgery should talk to their PCP about what their personal expectations should be for loss of excess weight. In addition, co-morbidities, such as diabetes, high blood pressure, sleep apnea and others are often reduced or may go into remission. Most will find they require fewer medicines throughout time and many will discontinue their medicines completely.

Risks:
Research indicates that some patients who undergo bariatric surgery may have unsatisfac­tory weight-loss or regain much of the weight that they lost. Some behaviors such as frequent snacking on high-calorie foods or lack of exercise can contrib­ute to inadequate weight-loss. Technical problems that may occur after the operation, like separated stitches, may also contribute to inadequate weight-loss. There are also other potential complications that may occur which have been listed below with each of the various procedures.

Remember, bariatric surgery is not the “easy way out.” This treatment option is a tool that patients use to lose weight. Surgery is a resource to help reduce weight and maintain weight-loss. Lifestyle adjustments encompassing behavioral, diet, physical activity and psychological changes are required for you to maintain a healthy quality of life. Continued positive weight-loss relies upon your desire and dedication to change your lifestyle with a proactive approach.

Throughout this section, you will see terms, such as “malabsorptive,” “restrictive,” “laparoscopic” and “open,” in which you may not be familiar. Prior to reading about the different surgeries, we have provided you with a brief description of some of the most commonly used terms when talking about bariatric surgery.

Open vs. Laparoscopic Procedures

In each section, you will see the surgeries described as being performed “open” or “laparoscopic.” Although the laparoscopic procedure has increasingly gained in popularity and frequency, open procedures are still used in practice today. The approach will depend on several factors, including surgeon experience as well as your surgical and medical history, which may influence one approach to be used over the other. Please be sure to discuss the surgical approach with your surgeon.

“Open” – The open procedure involves a single incision that opens the abdomen, which provides the surgeon access to the abdominal cavity. The incision can vary in length from as little as three inches to as large as six or more inches.

“Laparoscopic” – In laparoscopic surgery, a small video camera is inserted into the abdomen allowing the surgeon to conduct and view the procedure on a video monitor. Both camera and surgical instruments are inserted through small incisions made in the abdominal wall. The number of incisions will vary depending on the surgical procedure and surgeon experience. Some surgical procedures can be performed via a single incision while other procedures may involve six or more small incisions.

Malabsorptive vs. Restrictive

Throughout this section, the surgeries will be described as “malabsorptive,” “restrictive” or a combination of the two. Depending on the type of procedure that is determined to be best for your needs, each requires different lifestyle changes.

“Malabsorptive” – Malabsorptive procedures alter digestion, usually through the rerouting of the intestines, thus causing the nutrients in the food to be poorly digested and incompletely absorbed.

“Restrictive” – Restrictive procedures decrease food intake by creating a small upper stomach pouch to limit food intake.

Mechanical vs. Metabolic

Recent research indicates that each bariatric surgery works not only through the anatomical and mechanical changes from the procedure itself, but through metabolic changes in the “gut hormones.” Numerous studies have examined pre-operative and post-operative gut hormone levels after bariatric surgery. A brief summary of hormonal changes after each bariatric procedure is provided in the next sections. Some of these hormones are:

      • Ghrelin: functions primarily to stimulate appetite
      • Glucagon-like peptide 1 (GLP-1): mechanism of action includes increased satiety and reduced stomach emptying
      • Peptide YY (PYY): reduces appetite and increases efficiency of digestion and nutrient absorption

In addition to these terms, there may be other words, topics or descriptions that you might not understand. If so, make sure to speak with your physician further to gain a better understanding.

Bariatric Surgery Procedures

There is a great amount of importance and responsibility associated with choosing a weight-loss treatment option. Choosing which type of bariatric surgery is right for you can be a difficult task. It is our goal to provide you with education regarding the different types of bariatric surgeries. This knowledge can assist a discussion between your physician and you in deciding the most appropriate treatment selection for you.

The most commonly performed bariatric surgeries include:

      • Adjustable Gastric Banding
      • Sleeve Gastrectomy
      • Roux en-Y Gastric Bypass
      • Biliopancreatic Diversion with Duodenal Switch

Qualifications for each of the procedures are the same with the exception of the LAP-BAND® which has received FDA-approval for lower BMI’s. Please be sure to discuss the various surgical options with your physician to determine which procedure is best for you and your medical and surgical history.

Adjustable Gastric Banding

What is Adjustable Gastric Banding and how is it performed?

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This operation is a restrictive procedure and involves placing a silastic “belt” around the upper part of the stomach. The “belt” essentially separates the stomach into two parts: a tiny upper pouch and a larger lower pouch.

The band is connected by tubing to a port or reservoir that sits below the skin of the abdominal wall, usually around the belly button (the port site varies widely by surgeon). The port cannot be seen (and often cannot be felt) from the outside.

Inside of the “belt” is a balloon that can be filled by placing fluid through the port. As the balloon is filled, it slows the passage of food from the upper pouch into the lower pouch. As the band is progressively filled, patients will feel “full” with smaller amounts of food. You will work with your surgeon to determine the number of band fills or adjustments appropriate for you.

Weight-loss: Weight-loss with an adjustable gastric band is typically slow and steady. Band patients generally lose one to two pounds per week during the first year after band placement. In the first year, the average percent of excess weight-loss is significantly less with the laparoscopic adjustable gastric band than after gastric bypass. By three years, the percentage of excess weight-loss can approach that of gastric bypass.

Metabolic/Hormonal Changes: Increase Ghrelin = Increase hunger

There are several features that make the adjustable gastric band appealing. There is minimal stress to the body at the time of surgery, because the band is almost always done laparoscopically and does not involve cutting the stomach or rerouting the intestines. Most patients can go home the same day or the next morning. Recovery from surgery is usually quick and most people return to work a week or so after surgery. The adjustability of the band makes it unique among weight-loss operations. This feature allows the possibility of making band adjustments based on the individual weight-loss goals and needs of the patient. The stomach and intestines aren’t bypassed, so vitamin, mineral and nutrition problems after banding are less common. Many programs still recommend vitamin supplementation after banding.

Complications: Patients contemplating adjustable gastric banding must be comfortable with the thought of having a medical device in them for life. Although the band has an excellent safety profile, there are complications that can occur with any weight-loss operation, and the band is no different. It is important for patients to have routine follow-up with their healthcare team for adjustments and monitoring.

About 10 percent of patients will require a second operation to address a problem with their band.

Potential complications include band slippage or gastric prolapse, band erosion through the stomach or tubing leakage. The risk of death from band surgery is equal to or less than 0.1 percent (1 in 1000) within 30 days after surgery, although many centers report even lower rates. The adjustable gastric band can be removed, if necessary.

It is important to realize that the band is not a “short-term” fix. It is intended to be left in your body indefinitely. As with other medical devices implanted in the body, long term effects (20 to 30 years) are unknown at this time with the band.

After banding, especially in the first year after surgery when band adjustments may be required more frequently, patients need to be available for regular follow-up with their healthcare team. In deciding if banding is right for you, it is important to consider both time and distance involved in traveling to where the adjustments will be performed. Adjustments are made by filling the band through the port with fluid through a needle.

Band patients do not suffer adverse effects from eating sugars (dumping syndrome), so they need to be more disciplined in their food choices. Things like sodas, ice cream, cakes and cookies slide through the band easily, but obviously these choices will not lead to the desired goal of significant weight-loss.

Conclusion: Adjustable gastric banding is an effective weight-loss operation that can lead to meaningful, long-term weight-loss. No matter what weight-loss operation is chosen, individuals need to change their lifestyle and learn to work with the surgery in order to be successful.

Sleeve Gastrectomy

What is a Sleeve Gastrectomy?
The sleeve gastrectomy (LSG) originated as the restrictive part of the duodenal switch operation. In the last several years, it has been used by some surgeons as a staging procedure prior to a gastric bypass or duodenal switch in very high risk patients. It has also been used as a primary, stand-alone procedure by some bariatric surgeons.

How is the Sleeve Gastrectomy performed?
The majority of LSG’s performed today are completed laparoscopically. During the LSG, about 75 percent of the stomach is removed, leaving a narrow gastric tube or “sleeve.” No intestines are removed or bypassed during the procedure and it takes about one to two hours to complete. When compared to the gastric bypass, the LSG can offer a shorter operative time that can be an advantage for patients with severe heart or lung disease.

Weight-loss: LSG is a restrictive procedure. It greatly reduces the size of the stomach and limits the amount of food that can be eaten at one time. It does not cause decreased absorption of nutrients or bypass the intestines. After this surgery, patients feel full after eating very small amounts of food. LSG may also cause a decrease in appetite.

Metabolic/Hormonal Changes: In addition to reducing the size of the stomach, the procedure reduces the amount of the “hunger hormone,” ghrelin, produced by the stomach. The duration of this effect is not clear yet, but most patients have significantly decreased hunger after the operation.

Decrease Ghrelin = Decrease hunger
Increase PYY = Increase satiety
Increase GLP-1 = Increase satiety

Complications: LSG has been used successfully for many different types of individuals affected by severe obesity. Since it is a relatively new procedure, there is no data regarding weight-loss or weight-regain beyond three years. The risk of death from LSG is 0.2 percent (2 in 1000) within 30 days after surgery.

The risk of major post-operative complications after LSG is 5-10 percent, which is less than the risk associated with gastric bypass or malabsorptive procedures, such as duodenal switch. This is primarily because the small intestine is not divided and reconnected during LSG as compared to the bypass procedures. This lower risk and shorter operative time is the main reason for use as a staging procedure for high-risk patients.

Complications that can occur after LSG include: a leak from the sleeve can result in an infection or abscess, deep venous thrombosis (blood clot) or pulmonary embolism, narrowing of the sleeve (stricture) requiring endoscopic dilation and bleeding. Major complications requiring re-operation are uncommon after sleeve gastrectomy and occur in less than 5 percent of patients.

Conclusion: Several studies have documented excellent weight-loss up to three years after LSG. In higher BMI patients who undergo LSG as a first-stage procedure, the average patient will lose 40-50 percent of their excess weight in the first two years after the procedure. Patients with lower BMIs who undergo LSG will lose a larger proportion of their excess weight (60-80 percent) within three years of the surgery.

Roux-en-Y Gastric Bypass

What is a Roux-en-Y Gastric Bypass?
The Roux-en-Y gastric bypass operation has been performed since the late 1960’s to achieve significant weight-loss in people affected by severe obesity. The operation leads to weight-loss as a result of two different mechanisms:

      • A small stomach pouch reduces the amount you can eat (restriction) and
      • A small amount of intestine is bypassed leading to earlier release of gut hormones that make you feel less hungry

How is it performed?
A gastric bypass can be done through a single long incision (open) or through a series of small incisions (laparoscopic). Regardless of how the operation is done, the “inside part” is the same.

The surgery involves three basic steps:

      • Dividing the large stomach into two separate stomachs, thus creating a small pouch (proximal pouch of stomach) and a larger excluded lower pouch (remnant pouch of stomach)
      • Bypassing part of the small intestine (creating the “Short” Intestinal Roux Limb)
      • Attaching the bypassed intestine (Roux Limb) to the proximal pouch

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The operation can usually be done in two hours or less, but this will depend on many factors. Most patients will need to stay in the hospital for two to three days after their operation and should be ready to return to full activity within two weeks.

How does it work?
To understand how a gastric bypass leads to weight-loss, it is helpful to review what you probably learned in grade school: Human Digestion. When we swallow food, it goes down the esophagus and into the stomach. The stomach is able to hold huge amounts of food (think about a hot dog eating contest). The stomach then churns the food and mixes it with digestive juices to break the solid food down into a liquid form. That liquid food then leaves the stomach and goes into the small intestine where it can be absorbed to help fuel our bodies.

The small gastric pouch created during the gastric bypass limits the amount of food (calories) a person can eat during a meal. The pouch will initially hold a very small amount of food (about half a shot glass full or one tablespoon), however, by one-year after surgery, a gastric bypass patient will be able to eat a meal equal in size to what a seven or eight-year-old child could eat. Although the meals after gastric bypass surgery are much, much smaller than what they were before surgery, they still give the individual the same “full” or “satisfied” feeling they used to get with a much larger meal.

Until food is broken down into the liquid form, it cannot be absorbed by the small intestine. After a gastric bypass, the food does not turn into liquid until it leaves the “Short Intestinal Roux Limb” (see image of gastric bypass). The “Short Intestinal Roux Limb” therefore does not absorb all of the nutrients from food that is eaten (called malabsorption). This also means vitamins and minerals aren’t as well absorbed, so gastric bypass patients must be on vitamin and mineral supplements for the remainder of their life. The “Short Intestinal Roux Limb” does not handle sugar or starches well so gastric bypass patients must limit their intake of sugary and starchy foods. If they don’t, they may experience something referred to as “Dumping Syndrome.” Usually 10-15 minutes after eating a sugary or starchy food, the individual who is “dumping” begins to experience many of the following symptoms:

      • Sweating
      • Flushing skin
      • Rapid heart rate
      • Dizziness
      • Low blood pressure
      • Abdominal pain
      • Vomiting
      • Diarrhea
      • Shakiness
      • Fainting

Dumping typically lasts 30-45 minutes and then will go away. This gives the gastric bypass patient plenty of time to reflect on the food choice that they made that led to the dumping. For many people who have had a gastric bypass, dumping or the fear of dumping helps them make better food choices and stay away from foods that have tempted them in the past.

Weight-loss: Proper follow-up and participation in a multidisciplinary program that stresses lifestyle modification (dietary, behavioral and exercise changes) will improve the chances a gastric bypass patient will maximize their weight-loss and maintain it for a lifetime.

Metabolic/Hormonal Changes: In addition to reducing the size of the stomach, the procedure reduces the amount of the “hunger hormone,” ghrelin, produced by the stomach. The duration of this effect is not clear yet, but most patients have significantly decreased hunger after the operation.

Decrease Ghrelin = Decrease hunger
Increase PYY = Increase satiety
Increase GLP-1 = Increase satiety

Complications: The major complications that can occur early on after gastric bypass include bleeding, leakage, infections, bowel blockages, blood clots in the lungs (pulmonary emboli) and death. The chance of dying in the first 30 days after a gastric bypass is around 0.2-0.5 percent (2 to 5 in 1000).

Long-term complications that can occur after a gastric bypass include strictures, ulcers, hernias, weight regain, vitamin and mineral deficiencies and malnutrition. Most of the long-term problems linked to the gastric bypass operation can be prevented by follow-up with your healthcare team.

Conclusion: Gastric bypass is a weight-loss operation that can lead to significant and sustained weight-loss by reducing food intake and altering gastrointestinal hormones. While there are short and long-term risks associated with the surgery, most of these issues can be prevented through close follow-up. As with any weight-loss operation, the best results are achieved when the surgery is combined with a multi-disciplinary program that focuses on lifestyle and behavioral changes.

Biliopancreatic Diversion with Duodenal Switch

What is a Biliopancreatic Diversion with Duodenal Switch?
The Biliopancreatic Diversion with Duodenal Switch (BPD/DS) is often an open operative procedure; however, it may be performed laparoscopically.

How is the Biliopancreatic Diversion with Duodenal Switch performed?
BPD/DS is based on a smaller stomach and combines a lower restriction and a high level of malabsorption. The outer margin of the stomach is removed (approximately two thirds—similar to a sleeve gastrectomy) and the intestines are then rearranged so that the area where the food mixes with the digestive juices is short.

A portion of the stomach is then left with the pylorus still attached and the duodenum beginning at its end. The duodenum is then divided, allowing for the pancreatic and bile drainage to be bypassed. It is a pyloric saving procedure, which eliminates the “dumping syndrome” that is inherent to gastric bypass.

Weight-loss: The procedure allows for increased malabsorption, resulting in increased weight-loss. Foods high in fat content are not easily absorbed and will be eliminated along with the usually high calories associated with the high-fat.

In all bariatric surgery procedures, carbohydrates and sugars are absorbed, so eating foods high in sugar (and calories) will still cause unwanted weight gain or difficulty to lose weight. Additionally, emphasis is placed on nutritionally beneficial and nutrient dense foods. BPD/DS patients enjoy “normal” sized food portions at meals. The BPD/DS allows patients to increase portion size throughout, allowing for greater diversity in food consumption at each meal.

Metabolic/Hormonal Changes: In addition to the restrictive and malabsorptive nature of BPD/DS, it also has a positive impact on weight-loss and health via metabolic mechanisms. The alimentary limb absorbs proteins and sugars from ingested food but also secretes the hormone GLP-1 in the presence of undigested food. BPD/DS rearranges this portion of the intestine which causes food to be introduced into the alimentary limb earlier and ultimately enhances GLP-1 secretion.

Decrease Ghrelin = Decrease hunger
Increase PYY = Increase satiety
Increase GLP-1 = Increase satiety

Complications: The BPD/DS requires a much longer recovery period (usually six to eight weeks), causes the greatest risk for infection (due to the size of the incision, increased operative time and exposure of the digestive organs) and usually carries a 25 percent chance for development of incisional hernia post-operatively (due again to the length of the incision). The BPD/DS also carries the highest risk of nutritional deficiencies post-operatively due to malabsorption.

Vitamin B-12 deficiencies are not created by the BPD/DS. Of course, all patients are monitored for iron and B-12 as well as other fat-soluble vitamin deficiencies. BPD/DS patients are specifically monitored for fat-soluble vitamin deficiencies (A,D,E,K) along with zinc.

Patients who undergo BPD/DS are able to enjoy nutritional foods and eat more normally without the restriction of a small pouch (one to two ounces) as in a gastric bypass.

The BPD/DS is a more invasive operation. According to a recent analysis, BPD/DS carries a mortality rate of 1.1 percent (about 1 in 100) within 30 days after surgery.

Conclusion: Patients are always encouraged to maintain the commitment to lifestyle and food changes associated with weight-loss. BPD/DS patients are asked to first increase protein intake; then vegetables; and lastly, if able at all, breads, pastas or rice in very limited amounts.

Gaining Access to Treatment
Individuals affected by severe obesity rely on their insurance provider to assist them in the process of seeking access to safe and effective medical treatment. Many times they experience difficulty when working with their insurance providers, such as repeated denials of claims. In addition, the process often times seems complicated, and physically and emotionally draining. For more information on working with your insurance provider, please visit the OAC Web site and view the OAC’s Insurance Guide, titled “Working with Your Insurance Provider: A Guide to Seeking Weight-loss Surgery.”

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