Surgery for Weight Loss: The Facts

As anybody who has undergone the trials and trauma of surgery for weight loss will tell you. It is not an easy, quick fix to a great body.

Neither is surgery for weight loss for those who are too lazy to diet and exercise, as both of these are part of the pre and post-operative plan.

For some people, when lifestyle changes have not worked and obesity becomes a life-threatening condition then surgery may be the last resort but it is NOT an easy option.

100 laughs a day is equal to 10 minutes of exercise.

How can it get easier than that with Moose around?

Surgery?

Surgery for Weight Loss: A Last Resort?

Weight loss surgery 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 thinking about weight-loss surgery.

Why Moose? I don’t think that you would qualify.

Well, when I stepped on the scales yesterday, it said ..to be continued.

I’m interested in Weight Loss Surgery. What do I need to know beforehand?

Here are some questions to ask yourself before thinking about surgery for weight loss:-

Have you seriously tried losing weight and keeping it off using diet and lifestyle changes and setting weight-loss goals with little or no effect?
Have you researched different types of weight loss surgery and what the procedures involve? If not read on …
Are you fully aware of how life will be after the surgery? How you eat will change forever, you will not be able to eat large meals and your food choices may be limited. Consider the effects on your social and family life when eating is totally changed.
Are you really committed to pre and post-operative lifestyle changes? It is essential that exercise is included in your daily routine before and after weight loss surgery. As mentioned above, eating will never be the same again.
Are you prepared for lifelong medical follow up? Your progress and well being will need to be tracked for the rest of your life.
Are you happy to take extra food supplements and tablets? Due to the reduced amount of food and nutritional intake following weight loss, vitamin and mineral supplement are essential.
Are you prepared for rapid weight loss? Despite the fact that achieving an ideal weight may have been the goal for years. There are a whole host of new issues such as fatigue and altered body image to come to terms with.

I went to the police to report that somebody in a mask had cut me with a knife and taken all my money.

That’s awful Moose, what did they say?

They said that they can’t arrest my surgeon!

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 for surgery 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.

I don’t think that I would qualify for weight-loss surgery.

Why not? You can work out your Body Mass Index.

No, it’s not that. I don’t think I’d pass the psychiatric evaluation what with my imaginary friend and everything.

Squeeze In!

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.

Gastric banding reminds me of a joke … What did Zero say to the number 8? Nice belt!

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 postoperative 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.

Come on Doc. Give us the low down. How much weight loss can you expect with gastric banding?

Yes. Give us the figures … [pun intended]

How much weight will I lose?

The average amount of surgical weight loss is between 45 % and 65 % two years after surgery. Most of the excess weight is lost within the first year of surgery.

A 2011 scientific study that followed a group of patients with gastric bands found that the average long-term weight loss was 42.8 % after 12 years.

Wow! That’s around half your body weight lost.

No it is half of your excess weight. If you were very heavy to begin with then this may not be enough to benefit from all the health improvements.

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 postoperative 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 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 a period of 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.

Wow! That’s quite a list. There’s a lot more to this gastric banding than I first realized.

Yes, this is why all surgery for weight loss should be very carefully considered … and hold on … there’s more …

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 overeating or the band being too tight.

I’m not a fan of the lap band. Speaking as a radiologist who checks if they are in the right position, quite often they are found to have just slipped upward, off the stomach, and do nothing useful around the lower esophagus.

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.

Gastric Bypass

Gastric bypass or roux-en-y gastric bypass is another form of weight loss surgery. It works in a similar manner to the gastric band but is a little more radical.

A small stomach pouch is surgically created at the top of the stomach which is then connected to the small intestine, thus totally bypassing the rest of the stomach and bowel, hence the name. The intake of food is restricted in the same way as the band. But also your body can not absorb the same amounts of calories (or nutrients) from the food eaten.

Gosh, that is quite a radical procedure. Is it reversible?

It is considered a permanent operation but can be reversed but only for a medical emergency.

How many donuts could you eat after this?

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 an impressive weight loss.
Due to 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.

They say whatever diet you’re on you can eat as many vegetables as you like. I already do … none!

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 %.

Goodness, with those problems I’m surprised anybody has surgery for weight loss.

Remember Jess, weight loss surgery patients are 29% less likely to die following surgery than similarly obese people who choose not to.

Increased risk of complications and death

Gastric bypass is a major abdominal operation and carries some serious risks.

One research study followed 3,300 obese patients after gastric bypass from 1987 to 2001. The findings were surprising. It appears that after gastric bypass surgery, the risk increases.

The risk of death in the short term is 4 times higher than previous studies had suggested at 1.9 %. The risk of dying after gastric bypass surgery is increased 5 fold if the surgeon had done less than 20 bypass procedures.

The study concluded that most patients are informed that the risk of death within 30 days of the surgery is 1 in 200. But when all factors are taken into consideration it is actually around 1 in 50.

If the risk of death increases five times if the bariatric surgeons have not done more than 20 operations, what does that mean?

Make sure you choose a really old surgeon who has done lots then!

… yeah okay… but how are the new surgeons going to practice?

Gastric Bypass: Specific Problems

Leakage from the stapled part of the stomach, or the join to the small intestine. The leak allows stomach contents getting into the abdominal cavity leading to infection (peritonitis) and abscesses. Leakage is one of the most serious complications with an incidence rate of 0.4 % to 5.2 % and a death rate of 50 %.
Postoperative bleeding (hemmorhage) is a serious, but rare complication affecting between 1 – 4 % of patients. Sometimes bleeding is related to other complications listed here such as ulceration and leakage.
Ulceration: Ulcers are often a late complication following gastric bypass surgery and the incidence rate is around 20 %.
Small Bowel Obstruction: The most common cause of the bowel becoming trapped with possible loss of blood supply (ischemia) is a hernia. Incisional hernias occur in about 20 % of patients following gastric bypass surgery and internal hernias in around 2 to 10 %. Over time, however, internal hernias become the most common complication.
Stricture (or narrowing) of the stoma site. According to a 2009 study stricture occurred in 23 % of patients following gastric bypass surgery. This increased to nearly a quarter of patients depending on the stapling technique at the operation.
Fistula: A fistula following gastric surgery bypass is an abnormal reconnection from the new pouch to the old stomach. This is a relatively rare complication occurring in around 1.5 % to 6 % of patients.

Thing is, I don’t see myself as fat ~ I’m more a nutritional over-achiever.

Sleeve Gastrectomy

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 %.

Historically, gastric sleeve surgery was done as the first part of a duodenal switch procedure.

So why is it used as a stand alone procedure now?

Because although weight loss and improvement of conditions related to obesity are greater. So are the complications following a duodenal switch.

Disadvantages of Gastric Sleeve Surgery

Life long changes in eating habits and the need for on-going monitoring are the same as those listed above for Gastric banding.
Leakage at the staple line leads to stomach contents entering the abdominal space causing peritonitis. The leakage rate is a serious complication affecting between 1 % and 4 % of patients.
Gastro-esophageal Reflux complaints (indigestion and heart disease) are common following gastric sleeve surgery and occurred in around 27% of patients.
Post Operative Bleeding (hemmorhage) occurs in between 1 and 6 % of patients
Stenosis/Strictures occur in around 3.5 % of patients

I’ve seen a lot of these vertical stapling attempts, simply come apart later, so the narrow sleeve breaks open, and food can once again, go everywhere in the whole stomach.

Here’s an example of a stricture, which means a narrowing in the stomach. Below are two images from a barium swallow. You can see the stomach has successfully been made more narrow from the surgery, but the very narrow spot in the middle is a complication.

I asked the surgeon if I would be able to play the violin after my weight loss operation?

… and what did he say?

He said ‘Yes, of course’ which is brilliant because I couldn’t play the violin before.

Duodenal Switch

In this technique of surgery for weight loss, (also called biliopancreatic diversion with switch) a large part of the stomach (around 85 %) is removed.

A cylinder-shaped pouch is created that is connected to the last part of the small intestine. Alongside this diversion, the pancreatic duct and bile duct are redirected into the upper part of the small intestine. This is the most complicated of the procedures for surgery for weight loss.

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 from Dumping syndrome

That all sounds really good. Why aren’t more Duodenal Switch operations performed?

The Duodenal Switch is a more complex operation. And despite the best weight loss results there are very mixed views regarding the increased risks in the medical profession.

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 were 2.9% including:
- Anastomosis leaks,
- wound infection,
- dehiscence,
- postoperative 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 cited as a problem but 98 % of patients had normal levels 3 years after Duodenal Switch.

You suffer with dumping syndrome, don’t you Hector?

No! there’s nothing wrong with my bowel movements.

No, but you’ve been dumped so many times it has become a syndrome.

Conclusion

We have looked at the top four types of surgery for weight loss in this post.

Even though some of the complications and life changes are extreme, this evaluation was written with the intention of giving you a balanced but scientifically proven review.

The better informed you are before choosing if surgery for weight loss is right for you and which procedure may be best for you, the better the outcome.

Do not be put off by the information in this post because, even though there are associated risks with this type of surgery, the long term risks for ongoing obesity are greater.

In our next post on surgery for weight loss, we will be looking at one woman’s personal journey through the highs and lows of weight loss following surgery.

I’m not fat … I’m just easier to see!

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6 Reasons why weight loss is not working: If you are thinking of weight loss surgery because other methods of weight loss failed this article, based on medical research, could be of interest to you.
Motivation for Weight Loss: Weight loss is not all about the physical aspects of diet and exercise. A major key to success lies in your attitude and mindset. Learn some research-based methods to help you stay on track

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I’ve read 20 books on weight loss … None of them worked.

References

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 25^th 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 25^th 2016) https://www.ncbi.nlm.nih.gov/pubmed/21631845

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