Surgery for weight Loss: A Last Resort?
Surgery for weight loss that is performed with the express aim of helping people lose weight is collectively called Bariatric Surgery. Obviously, undergoing the surgeon’s knife to lose weight must only be considered after all other avenues of non-surgical weight loss have been explored and have failed.
Resorting to surgery for weight loss is quite a drastic measure, but for some morbidly obese people, bariatric surgery can lower death rates. Especially for those with weight related complications. The easiest and most obvious route to weight loss is to make small steps, or gradual changes. In lifestyle, eating habits and exercise routines. Despite best efforts this approach is not always effective for everybody. There may be reasons why you are not losing weight which should be explored before considering weight loss surgery.
I’m interested in Weight Loss Surgery. What do I need to know beforehand?
Who can have Surgery for Weight Loss?
Only certain patients will meet the criteria for weight loss surgery. As the incidence of class III obesity has continued to increase over recent years, more and more people will qualify. At present whether a patient is eligible surgery for weight loss depends on Body Mass Index (BMI) measurements. The National Institute of Health (NIH) sets the following guidelines for surgery:-
- A Body Mass Index (BMI) of 40 or over (Class III Obesity or morbidly obese)
- A Body Mass Index (BMI) of 35 or over with at least one health problem related to obesity, such as hypertension (high blood pressure), diabetes, sleep apnea or heart disease.
- The US Food and Drug Administration (FDA) and the UK’s National Institute for Health and Care Excellence (NICE) will consider some types of surgery. For those with a body mass index (bmi) of 30 or over with an existing health condition or newly diagnosed Type II diabetes.
- Patients must prove they have explored and failed using alternative weight loss methods and have at least a 5 year history of obesity.
- Patients must be in reasonable health and able to safely go under a general anesthetic.
- A psychiatric evaluation must be passed before surgery for weight loss.
Adjustable Gastric Banding is minimally invasive surgery performed using laparoscopy. To insert an inflatable band around the stomach, which divides it into a small upper section and a larger lower section. The two divisions of the stomach stay joined together by a very narrow channel. The surgeon can control the size of the band by inflating and deflating it through a port under the skin. This procedure serves to slow down the emptying of the stomach from the upper pouch and dramatically restricts food intake.
Why choose Gastric Banding?
- Gastric banding (sometimes called lap band surgery) is a reversible kind of weight loss surgery. It does not involve any of the stomach or digestive tract being removed and so food and nutrients are absorbed in the same way.
- It is the safest of operations for weight loss with a low mortality rate. In a 12 year study the death rate from the procedure was 0 %. Gastric banding has a lower post-operative complication rate than any of the other Bariatric procedures.
- It is performed by minimally invasive laparoscopy which lowers the risk of infection and some of the other surgical complications.
- Any further operations or bariatric procedures can also be performed by laparoscopy
- Results are effective (but do depend on the commitment and adherence to the regime of the patient).
- Lowers the risk of death from complications associated with obesity. According to a 2007 scientific study on 821 patients, 40% achieved a stable excess weight loss. This research compared patients who had gastric band surgery with a control group of obese patients. The surgical group were found to have a 5-year 60% lower risk of death.
How much weight will I lose?
Disadvantages of the Adjustable Gastric Band
- The changes in your eating are radical: You will NOT be able to eat a big meal again whilst the gastric band is in place. The first 4 weeks following the diet you can only take liquid or pureed foods. Once a ‘normal’ diet is re-established you must chew all food for a long time and the portions are still very small. ( 2- 3 tablespoons in the early stages and a small plate later). Fluids can NOT be taken with meals. Overeating leads to vomiting and discomfort. Some foods will no longer be tolerated common ones are white bread, rice and red meat.
- The post-operative monitoring is intense. The gastric band must be adjusted every 4 – 6 weeks after the operation for the first year to 18 months. This helps control the weight loss.
- Weight loss results are not as effective with gastric banding as some of the other weight loss surgeries. Weight is often regained over time or the results are disappointing. Patient and team commitment are essential
- Nutritional deficiencies: Vitamin and mineral supplements may be required on a long term basis.
- Gastric band surgery has less early complications but a lot more late ones (i.e. months or years later). The re-operation rate for gastric banding has been estimated between 10 and 15% but may be higher. In a scientific study following 151 patients it was found that 22 % of patients had minor complications and 39 % had major complications later. Overall the long term revisional bariatric surgery rate was 60 % which is over half and fairly high.
Gastric Banding: Specific Problems
- Band erosion: Over time the gastric band can erode and will need to be removed. In the patients from the above 12 year study 28 % experienced band erosion and 1 in 3 needed their gastric bands removing.
- Band Slippage: The gastric band can slip and part of the stomach may become trapped which may lead to ischemia (loss of blood supply) and infection. Signs of this can be increased vomiting, difficulty swallowing (dysphagia) and heartburn.
- Gastric pouch dilatation: Think of a balloon and the small part of the stomach above the band balloons out or dilates. This is often due to over eating or the band being too tight.
X-Ray example of a slipped band
Here’s an example. A slim band was a little too tight, causing the esophagus to fill up with fluid, leading to coughing. So the doctors reduced it’s inflation a little bit, then it became too loose. It slipped up, off the stomach to surround the distal esophagus, thereby having no effect whatsoever.
Why choose Gastric Bypass Surgery?
- The weight loss results are FAST and dramatic in the short term ~ not that surprising really as the stomach is reduced to around the size of an egg. A scientific study that evaluated patients 8 years after roux-en-y surgery. It found that weight loss was around 68 % in the first year, 72 % in the second year and around 67 % after 8 years. That is impressive weight loss.
- Due to the dramatic weight loss secondary health conditions can occur. But also improvements for High blood pressure, diabetes, heart disease and sleep apnea. These are associated with Class II and III obesity are greatly improved with lasting effects.
Disadvantages of Gastric Bypass Surgery
- Life long changes in eating habits and the need for on-going monitoring are the same as those listed above for Gastric banding.
- Gastric Bypass Surgery is irreversible.
- Nutritional deficiencies are more of a risk as nutrient intake is restricted and absorption is affected too. Iron and calcium deficiencies are common as are vitamin and protein deficiencies which can result in life threatening conditions. Regular blood tests and life long nutrient supplements are essential.
- Failure to maintain weight loss long term: Although short term weight loss results are impressive scientific research carried out 10 years after the operation on 272 patients, found some worrying results. There was a significant increase in Body Mass Index (BMI) in the two groups of patients. Those with a starting BMI of over 40 (morbidly obese) and those with a BMI of over 50 (super obese). At the 10 year point the failure rate for the morbidly obese was 20.4 % and for the super obese was 34.9 %.
- Dumping Syndrome is an unpleasant side effect following gastric bypass surgery. Dumping syndrome happens when undigested food passes too quickly from the stomach into the small intestine. In a scientific study involving 50 patients following gastric bypass surgery dumping syndrome affected 42 %.
Increased risk of complications and death
Gastric Bypass: Specific Problems
The vertical Sleeve Gastrectomy involves removing 75 – 80 % of the stomach. In this form of weight loss surgery, the incision is made vertically and the much smaller pouch is around the size of a banana.
Why Choose Gastric Sleeve surgery?
- Due to the fact that the sleeve gastrectomy is a relatively new weight loss surgery for obesity, long term results are a little lacking. A scientific study showed that the average excess weight loss was 72.8 % 3 years after surgery, however, this had dropped to 57.3 % after 6 years. This is still comparable with gastric bypass surgery, although slightly less.
- The operation is performed by laparoscopy and is quicker and less complicated than gastric bypass surgery.
- Research has shown that hunger is greatly reduced and satiety increased following sleeve gastrectomy. This may be due to the physiology involved in the part of the stomach that is removed. This study suggests that this is due to accelerated gastric emptying and reduced ghrelin (gut hormone) release. This helps weight loss and also glucose metabolism issues after surgery.
- Patients following a sleeve gastrectomy do not suffer from dumping syndrome.
- Absorption of nutrients is better than gastric bypass surgery as there is no bypassing of the intestine although supplements may still be necessary.
- Complication rates following surgery are lower than those for gastric bypass. Risk of death is low at just 0.8 %.
Disadvantages of Gastric Sleeve Surgery
|Here’s an example of a stricture, which means a narrowing in the stomach. 2 images from a barium swallow. You can see the stomach has successfully been made slender from the surgery, but the narrow spot in the middle is a complication.|
Why Choose Duodenal Switch
- The Duodenal Switch, although a more complex procedure, has the greatest weight loss overall compared to any other of the weight loss surgeries.
- The Duodenal Switch operation has greater weight loss results than Gastric Bypass surgery in the super obese. Super obese applies to those patients with a Body Mass Index (BMI) of over 50. A scientific study that followed 350 super obese patients found that weight loss at:-
12 months was 64.1 % for Duodenal Switch compared to 55.9 % for Gastric Bypass
18 months was 71.9 % for Duodenal Switch compared to 62.8 % for Gastric Bypass
24 months was 71.6 % for Duodenal Switch compared to 60.1 % for Gastric Bypass
36 months was 68.9 % for Duodenal Switch compared to 54.9 % for Gastric Bypass
- The Duodenal Switch had better results in the improvement and resolution of obesity related conditions regardless of weight loss, than the gastric bypass. Studies have shown improvements to these conditions. Diabetes (Type II has a 98 % cure), hypertension (high blood pressure), high cholesterol, hyperlipidemia, and sleep apnea.
- Eating habits after Duodenal Switch are much more normal. Due to the fact that weight loss occurs through not absorbing nutrients as well. Patients following a duodenal Switch operation can eventually eat a normal diet in smaller portions.
- Patients do not suffer with Dumping syndrome
Disadvantages of the Duodenal Switch
- The Duodenal Switch is the most complex of the surgery for weight loss procedures and the time on the operating table is longer. (3 – 4 hours) increases the general risks of surgery such as pulmonary embolism and myocardial infarction.
- Recent research has indicated that the mortality rate following duodenal switch is around 1.4 %. Deaths from complications was 2.9% including:
- Anastomosis leaks,
- wound infection,
- post operative haemorrhage
- and splenectomy.
It must be taken into consideration however that patients undergoing this type of surgery for weight loss are morbidly obese. This increases the risk of surgery.
- Revisional surgery to increase the length of the common channel is a complication and occurs in around 5 % of patients
- There is a need for continued follow up and dietary supplements to monitor nutritional status. Fat is not absorbed very well following duodenal switch and this can lead to diarrhea and fat soluble vitamin deficiencies (A,D,E and K). Calcium and iron deficiencies can be a problem following Duodenal Switch leading to anemia and osteoporosis. However, 3 years following the operation 71 % of patients had normal levels of calcium. And over half had normal levels of haemoglobin. Protein deficiency has also been sited as a problem but 98 % of patients had normal levels 3 years after Duodenal Switch.
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- Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. (2012) Bariatric Surgery: A Systematic Review and Meta-analysis JAMA. 2004;292(14):1724-1737 (Retrieved January 25th 2016) https://www.ncbi.nlm.nih.gov/pubmed/15479938
- Chang J, Wittert G.(2009) Effects of bariatric surgery on morbidity and mortality in severe obesity. Int J Evid Based Healthc. 2009 Mar;7(1):43-8 (Retrieved January 25th 2016) https://www.ncbi.nlm.nih.gov/pubmed/21631845