Weight Loss Surgery

Overview

What is weight loss surgery?

Obesity is a disease that has numerous adverse effects on health. It can also have a significant psychological and social impact on affected individuals, directly affecting their quality of life. Most significantly, obesity is associated with diabetes, heart disease, certain types of cancer, and a reduced life span.

Lifestyle modifications – in the form of exercise and altered dietary habits – are touted as the best way to lose weight, but many people find it hard to shed the pounds even after years of trying. Even intense lifestyle modifications result in an average of about 10% weight loss after one year, but only about half of that is maintained by eight years.

The simple fact is, through diet and exercise, most people cannot achieve and maintain the weight loss they need to improve their health and happiness. If you are significantly overweight, or your excess weight is causing health issues, weight loss surgery, known as bariatric surgery (“bariatrics” is the branch of medicine that deals with the treatment of obesity), may be right for you.

Are you a candidate?

The consensus guidelines covering the criteria for eligibility for bariatric surgery were developed by the U.S. National Institutes of Health in 1991, and have not changed since then. The criteria are:

• BMI (body mass index) of 40 or greater without significant obesity-related health conditions, or
• BMI of 35 or greater with at least one serious obesity-related health condition, including (but not limited to):
• Type 2 diabetes
• High blood pressure (hypertension)
• Obstructive sleep apnea
• High cholesterol (hyperlipidemia)
• NASH/NAFLD (non-alcoholic steatohepatitis/ non-alcoholic fatty liver disease – inflammation and dysfunction of the liver due to excess fat build-up)
• Obesity hypoventilation syndrome (a condition where obesity limits breathing to the point where oxygen is low and carbon dioxide is high in the blood)

Tried proper diet and exercise It is important to understand that bariatric surgery is not intended as a replacement for a proper diet and exercise, but rather as a weight loss option for those who have tried unsuccessfully to lose weight through lifestyle modifications. Many bariatric surgeons (and medical insurance plans) require a serious attempt at weight loss for a specified period of time before surgery can be considered.

Willing to adopt significant lifestyle changes People must also be prepared to adopt and maintain significant lifestyle changes following the procedure. Having bariatric surgery does not mean that people can eat whatever they want or live a sedentary lifestyle without any consequences. It’s possible to gain back the weight they lost.

Specific dietary precautions As well, specific dietary precautions are necessary on an ongoing basis following surgery. For example, the amount of food that can be ingested will change, certain foods must be avoided, and certain nutritional supplements may have to be used (depending on the type of surgery).

Weight loss prior to the surgery Most surgeons require a certain amount of weight loss prior to the surgery. This is so that patients can demonstrate that they have the ability and commitment necessary to engage in meaningful lifestyle modifications, and it also reduces the risk of complications during the surgery itself. In particular, even modest amounts of weight loss will reduce the size of the liver which makes the surgery easier and safer to perform.

Screening process Even if you meet the above guidelines, there are other requirements that must be satisfied to qualify for surgery. For example, you will likely go through an extensive screening process that involves interviews, exams, and laboratory testing with a team of health care professionals. This testing will typically involve a doctor, psychologist, dietician, and surgeon. During the evaluation, the team will consider your:

• Current medical condition (to identify surgical or anesthetic risks)
• Weight history and nutrition
• Psychological status (to rule out undiagnosed mental health disorders or drug or alcohol abuse)
• Social support system
• Motivation
• Ability to observe lifelong nutritional requirements

Types of weight loss surgery

There are a variety of bariatric surgery options from which to choose. The right choice for you depends on your goals, your current health, your surgeon’s preference, and your budget among other factors.

Traditionally, bariatric procedures have been classified as either restrictive (reducing the size of the stomach, thereby limiting the amount of food that can be consumed), malabsorptive (disrupting the body’s ability to absorb nutrients), or a mixture of both. Some of the various procedures available include:

• Roux-en-Y gastric bypass. Gastric bypass is a mixed bypass procedure. The stomach is surgically divided, and a pouch is created that holds about one ounce of food (compared to about three pints before surgery). Then, the pouch is connected with the small intestine in a way that bypasses much of the first part of the intestinal tract.
• Vertical sleeve gastrectomy. Gastric sleeve is a form of restrictive surgery, about 80% of the stomach is removed, creating a small tube-like (“sleeve”) stomach. This reduces the amount of food the stomach holds, and accelerates emptying of the stomach.
• Biliopancreatic diversion with duodenal switch. During this mixed surgical procedure, a sleeve gastrectomy is performed, and the lower part of the small intestine is attached to the stomach, thereby bypassing much of the small intestine (specifically, the duodenum). The Duodenal Switch is not used very often due to a higher incidence of complications (both in the short- and long-term).
• Gastric banding. In this restrictive procedure, a band is placed around the stomach, thereby creating a small stomach pouch and stomach outlet. Some gastric bands are adjustable, and the size of the stomach pouch and rate of stomach emptying can be adjusted by a balloon device that is accessed through a port just under the skin. The Lap Band System is an example of adjustable gastric banding product. A similar technique, known as vertical banded gastroplasty, divides the stomach using a band along with surgical staples.
• Endoscopically placed devices. A number of incision-free devices and procedures that are placed or performed by using a minimally invasive scope are under development or just entering clinical use. For example, the gastric balloon procedure involving the placement of a balloon into the stomach to decrease the amount of available food space has recently been approved for use in the U.S. by the FDA. (Wolfe et al., 2016) The balloon may be left in place for up to six months. Another endoscopically-placed device is the endoluminal sleeve, a thin plastic sleeve that is placed in the upper part of the intestine to block food absorption.
• Intermittent vagal blockade. In this innovative procedure, electrical stimulation leads are placed around the nerve that innervates the stomach (the vagal nerve), and produce a reduced appetite and earlier feeling of fullness (satiety) by stimulating the nerve. This is an example of a procedure that is neither restrictive nor malabsorptive.

The vertical sleeve gastrectomy and the Roux-en-Y gastric bypass are the most commonly performed types of bariatric surgery in the U.S. Choosing a specific surgical approach will require close consultation with your doctor. No one technique is preferred for all patients, so your choice will depend on your specific situation.

Are there potential risks?

The risks involved in bariatric surgery depend heavily on the specific procedure and/or product that you choose. The procedures range from major surgery with irreversible changes (such as the Roux-en-Y gastric bypass) to relatively minor outpatient, non-operative procedures with temporary devices (such as the endoscopically placed gastric balloon). Your surgeon will have a detailed discussion with you about the potential risks, expectations, and possible outcomes of the procedure that you choose. Some possible risks associated with surgery in general include:

• Adverse reactions to anesthesia
• Excessive bleeding
• Blood clots
• Breathing problems
• Infection

Risks that are specific to some bariatric procedures include:

• Anastomotic leak – when the attachments of the stomach to the intestines leak
• Internal hernia – when bowel protrudes through surgically created openings
• Stomal stenosis – blockage of the surgically created tract
• Gastric or duodenal ulcers – these are a common side effect, so surgeons usually advise using a daily antacid medication.
• “Dumping syndrome” – where the stomach empties into the intestines too rapidly, causing pain, cramping, vomiting, diarrhea, and other symptoms
• Gallstones – a common complication of rapid weight loss.

There are also longer-term risks and complications that could occur after your surgery, such as:

• Constipation
• Nutritional deficiencies
• Altered absorption of medications
• Faster absorption and reduced tolerance of alcohol
• Nutritional deficiencies that adversely affect pregnancy
• Bowel obstruction
• Low blood sugar
• Gaining back the weight

How long will the recovery take?

The recovery time depends heavily on the type of surgery and is largely surgeon and institution dependent.

For example, a Roux-en-Y gastric bypass will require a hospital stay and bed rest, while many laparoscopic procedures are done on an outpatient basis. Your surgeon will discuss the specifics about recovery time, functional limitations, and time needed off work for your particular procedure.

Some patients will require assistance for activities such as getting dressed, moving around, and preparing food for a day or two, while others will need several weeks of assistance.

Patients can usually drive within two weeks and resume their normal activity level within six weeks of surgery.

After surgery, substantial lifestyle changes are necessary. Patients are temporarily restricted to a diet of clear liquids such as broth, fruit juice, or gelatin desserts. This diet must be continued until the gastrointestinal tract has recovered from the surgery.

The next phase is a blended or pureed diet for at least two weeks. Diet restrictions during and following the recovery period depend in part on the type of bariatric procedure performed.

After surgery, overeating may cause nausea or vomiting. Patients may need to take a daily multivitamin to compensate for reduced nutrient absorption in the digestive tract.

Most doctors recommend a post-surgery diet that is high in protein and low in fat.

When will I see results?

In general, during the first 30 days after weight loss surgery the average patient’s weight loss is between 5 to 15 pounds per week. Males tend to lose weight at a faster pace than women. After 2 months, most patients average a 20% loss of excess weight. Some patients may lose 30 to 50 percent of their excess weight in the first six months, and 77 percent of excess weight as early as 12 months after surgery.

It’s important to keep in mind results vary between patients and this surgery should not be looked at as a “quick fix” for weight loss.

How much does it cost?

Depending on the type of bariatric surgery, the cost can range from $7,423 to $33,541, according to a large systematic review of published cost analyses. This includes the cost for the surgeon as well as expenses related to pre-op medical tests, anesthesia, and the hospital facility. These costs can vary based on many factors, such as:

• Geographic location
• The particular surgeon and facility
• The medical device (i.e. the particular brand of band or sleeve used)
• The length of time you spend recovering in the hospital.

Will insurance cover my surgery?

Because obesity has both esthetic and medical implications, some or all of the cost may be covered by health insurance. This is particularly true if your doctor can establish medical necessity. Your doctor may also need to provide documentation that you have been on a physician-supervised diet and exercise plan for six months or longer prior to surgery.

Most cases of morbid obesity (a BMI of 40 or higher) are covered by health insurance. If obesity has contributed to serious health concerns such as heart disease or diabetes, your surgery is more likely to be covered by insurance. If you are concerned about insurance coverage for your weight loss treatment, be sure to ask for details before undergoing surgery.

There will likely be a pre-authorization process involving medical tests, letters from your doctor, and other steps for you to be approved for coverage. Some policies may provide coverage only for certain types of weight loss surgery methods. Some will only cover the cost of the surgery itself, while others cover all related expenses. Make sure that you know what your insurance will and will not cover before scheduling the surgery.

Medicaid and Medicare offer full coverage for laparoscopic gastric bands, gastric sleeve, and gastric bypass procedures for individuals who meet their criteria. Their criteria for coverage are a little more stringent than the general eligibility criteria for bariatric surgery. As with private insurance, your surgeon’s office will have the detailed information you need to check for Medicaid/Medicare coverage.

When it comes to the costs that are not covered by insurance, there are many payment plans and other financing options available. Talk to your surgeon about options to make weight loss surgery affordable for you.

Post-bariatric procedures

In addition to the cost of the surgery itself, there are also related expenses that you should consider when making decisions about bariatric surgery. These include nutritional supplements and other specialized dietary requirements, time off work, and fitness expenses. As well, some individuals later consider body contouring surgeries to lift sagging areas and remove excess skin. Some of these procedures include:

• Body lift
• Thigh lift
• Panniculetomy
• Abdominoplasty (Tummy Tuck)
• Arm lift (Brachioplasty)
• Breast lift
• Butt lift

Ready to take the next step?

To learn if you are a good candidate for weight loss surgery, contact a bariatric surgeon near you.