Severe Obesity: Why the Need for Surgical Intervention

Severe obesity is one of the most serious stages of obesity. You may often find yourself struggling with your weight and essentially feeling as if you’re trapped in a weight gain cycle. In addition, you most likely have attempted numerous diets – only in the end, to see your weight continue to increase.

Individuals affected by severe obesity are resistant to maintaining weight loss achieved by conventional therapies, such as consuming fewer calories, increasing exercise, commercial weight-loss programs, etc.). The fact is well recognised that bariatric (weight-loss) surgery is the only effective treatment to combat severe obesity and maintain weight loss in the long term.

How Can Bariatric Surgery Help Me?

When combined with a comprehensive treatment plan, bariatric surgery may often act as an effective tool to provide you with long term weight-loss and help you increase your quality of health. Bariatric surgery has been shown to help improve or resolve many obesity-related conditions, such as type 2 diabetes, high blood pressure, heart disease, and more. Frequently, individuals who improve their weight find themselves taking less and less medications to treat their obesity-related conditions.

Significant weight loss through bariatric surgery may also pave the way for many other exciting opportunities for you, your family, and most importantly – your health.

How Does Bariatric Surgery Work?

Bariatric surgery, such as gastric bypass, gastric sleeve, and laparoscopic adjustable gastric banding, work by changing the anatomy of your gastrointestinal tract (stomach and digestive system) or by causing different physiologic changes in your body that change your energy balance and fat metabolism. Regardless of which bariatric surgery procedure you and your surgeon decide is best for you, it is important to remember that bariatric surgery is a “tool.” Weight loss success also depends on many other important factors, such as nutrition, exercise, behavior modification, and more.

By changing your gastrointestinal anatomy, certain bariatric procedures affect the production of intestinal hormones in a way that reduces hunger and appetite and increases feelings of fullness (satiety). The end result is reduction in the desire to eat and in the frequency of eating. Interestingly, these surgically-induced changes in hormones are opposite to those produced by dietary weight loss. Let’s take a closer look at the differences in hormonal changes between surgery and dietary weight loss:

  • Bariatric Surgery and Hormonal Changes
    Hormonal changes following bariatric surgery improve weight loss by maintaining or enhancing energy expenditure (calories burned). In fact, some surgeries even increase energy expenditure relative to changes in body size. Thus, unlike dietary weight loss, surgical weight loss has a higher chance of lasting because an appropriate energy balance is created.
  • Dieting and Hormonal Changes
    In dietary weight loss, energy expenditure is reduced to levels lower than would be predicted by weight loss and changes in body composition. This unbalanced change in energy can often lead to weight regain.

Significant weight loss is also associated with a number of other changes in your body that help to reduce defects in fat metabolism. With increased weight loss, you will find yourself engaging in more physical activity. Individuals who find themselves on a weight-loss trend often engage in physical activity, such as walking, biking, swimming, and more. Additionally, increased physical activity combined with weight loss may often improve your body’s ability to burn fat, lead to a positive personal attitude, and decrease stress levels. Massive weight loss, as a result of bariatric surgery, also reduces hormones such as insulin (used to regulate sugar levels) and cortisol (stress hormone) and improves the production of a number of other factors that reduce the uptake and storage of fat into fat storage depots. Physical activity is also a very important component of combating obesity.

Bariatric surgery may improve a number of conditions and biological actions (hormonal changes) to reverse the progression of obesity. Studies find that more than 90 percent of bariatric patients are able to maintain a long-term weight loss of 50 percent excess body weight or more.

Bariatric surgery can be a useful tool to help you break the vicious weight gain cycle and help you achieve long term weight loss and improve your overall quality of health and life.

Long Term Weight Loss Success

Bariatric surgeries result in long-term weight-loss success. Most studies demonstrate that more than 90 percent of individuals previously affected by severe obesity are successful in maintaining 50 percent or more of their excess weight loss following bariatric surgery. Among those affected by super severe obesity, more than 80 percent are able to maintain more than 50 percent excess body weight loss.

Improved Longevity

Several large population studies find that individuals affected by severe obesity who have had bariatric surgery have a lower risk of death than individuals affected by obesity who do not have surgery. One of these studies found up to an 89 percent greater reduction in mortality throughout a 5-year observation period for individuals who had bariatric surgery when compared to those who did not. Another large population study comparing mortality rates of bariatric and non-bariatric patients found a greater than 90 percent reduction in death associated with diabetes and a greater than 50 percent reduction in death from heart disease.

The mortality rate for bariatric surgery (3 out of 1000) is similar to that of a gallbladder removal and considerably less than that of a hip replacement. The exceptionally low mortality rate with bariatric surgery is quite remarkable considering that most patients affected by severe obesity are in poor health and have one or more life-threatening diseases at the time of their surgery. Therefore, as regards mortality, the benefits of surgery far exceed the risks.

Improvement/Resolution of Coexisting Diseases

The exceptionally high reduction in mortality rates with bariatric surgery are due to the highly significant improvement in those diseases that are caused or worsened by obesity.

Bariatric surgery is associated with massive weight-loss and improves, or even resolves (cures), obesity-related co-morbidities for the majority of patients. These co-morbidities include high blood pressure, sleep apnea, asthma and other obesity-related breathing disorders, arthritis, lipid (cholesterol) abnormalities, gastroesophageal reflux disease, fatty liver disease, venous stasis, urinary stress incontinence, pseudotumor cerebri, and more.

Bariatric surgeries also lead to improvement and remission of Type II diabetes mellitus (T2DM). In the past, diabetes was considered to be a progressive and incurable disease. Treatments include weight loss and lifestyle changes for those who are overweight or obese and antidiabetic medication, including insulin. These treatments help to control T2DM but rarely cause remission of the disease. However, there is now a large body of scientific evidence showing remission of T2DM following bariatric surgery. A large review of 621 studies involving 135,247 patients found that bariatric surgery causes improvement of diabetes in more than 85 percent of the diabetic population and remission of the disease in 78 percent. Remission of T2DM was highest for the bilio-pancreatic diversion with duodenal switch (BPD/DS) with a remission rate of 95 percent, followed by the Roux-en-Y gastric bypass (RYGB) with remission in 80 percent of patients, and the adjustable gastric band (AGB) with a remission rate of 60 percent. Other studies comparing remission of diabetes between surgeries found comparable rates between the laparoscopic sleeve gastrectomy (LSG) and RYGB, i.e. 80 percent.

Causes of improvement or remission of diabetes have not been completely identified. Improvement of T2DM with AGB is related to weight loss. However, with other surgeries, such as the LSG or RYGB, diabetes remission or improvement occurs early after surgery – well before there is significant weight reduction. In fact, some bariatric patients with T2DM leave the hospital with normal blood sugar and without the need for antidiabetic medication.

Changes in Quality of Life and Psychological Status with Surgery

In addition to improvements in health and longevity, surgical weight-loss improves overall quality of life. Measures of quality of life that are positively affected by bariatric surgery include physical functions such as mobility, self-esteem, work, social interactions, and sexual function. Singlehood is significantly reduced, as is unemployment and disability. Furthermore, depression and anxiety are significantly reduced following bariatric surgery.

Qualifications for bariatric surgery in most areas include:

  1. BMI > 40, or more.
  2. BMI >35 and at least one or more obesity-related co-morbidities such as type II diabetes (T2DM), hypertension, sleep apnea and other respiratory disorders, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease.
  3. BMI > 27.5 with Diabetes  for suitable Asian candidates

For example, an adult who is 5’11” tall and weighs 290 lbs would have a BMI over 40. Calculate your BMI.

Bariatric surgical procedures cause weight loss by restricting the amount of food the stomach can hold, causing malabsorption of nutrients, or by a combination of both gastric restriction and malabsorption. Bariatric procedures also often cause hormonal changes. Most weight loss surgeries today are performed using minimally invasive techniques (laparoscopic surgery).

The most common bariatric surgery procedures are gastric bypass, sleeve gastrectomy, adjustable gastric band, and biliopancreatic diversion with duodenal switch. Each surgery has its own advantages and disadvantages.

Jump to a Procedure


Gastric Bypass

gastric_bypass

The Roux-en-Y Gastric Bypass – often called gastric bypass – is considered the ‘gold standard’ of weight loss surgery.

The Procedure

There are two components to the procedure. First, a small stomach pouch, approximately one ounce or 30 milliliters in volume, is created by dividing the top of the stomach from the rest of the stomach. Next, the first portion of the small intestine is divided, and the bottom end of the divided small intestine is brought up and connected to the newly created small stomach pouch. The procedure is completed by connecting the top portion of the divided small intestine to the small intestine further down so that the stomach acids and digestive enzymes from the bypassed stomach and first portion of small intestine will eventually mix with the food.

The gastric bypass works by several mechanisms. First, similar to most bariatric procedures, the newly created stomach pouch is considerably smaller and facilitates significantly smaller meals, which translates into less calories consumed. Additionally, because there is less digestion of food by the smaller stomach pouch, and there is a segment of small intestine that would normally absorb calories as well as nutrients that no longer has food going through it, there is probably to some degree less absorption of calories and nutrients.

Most importantly, the rerouting of the food stream produces changes in gut hormones that promote satiety, suppress hunger, and reverse one of the primary mechanisms by which obesity induces type 2 diabetes.

Advantages

  1. Produces significant long-term weight loss (60 to 80 percent excess weight loss)
  2. Restricts the amount of food that can be consumed
  3. May lead to conditions that increase energy expenditure
  4. Produces favorable changes in gut hormones that reduce appetite and enhance satiety
  5. Typical maintenance of >50% excess weight loss

Disadvantages

  1. Is technically a more complex operation than the AGB or LSG and potentially could result in greater complication rates
  2. Can lead to long-term vitamin/mineral deficiencies particularly deficits in vitamin B12, iron, calcium, and folate
  3. Generally has a longer hospital stay than the AGB
  4. Requires adherence to dietary recommendations, life-long vitamin/mineral supplementation, and follow-up compliance

Sleeve Gastrectomy

gastric_sleeve

The Laparoscopic Sleeve Gastrectomy – often called the sleeve – is performed by removing approximately 80 percent of the stomach. The remaining stomach is a tubular pouch that resembles a banana.

The Procedure

This procedure works by several mechanisms. First, the new stomach pouch holds a considerably smaller volume than the normal stomach and helps to significantly reduce the amount of food (and thus calories) that can be consumed. The greater impact, however, seems to be the effect the surgery has on gut hormones that impact a number of factors including hunger, satiety, and blood sugar control.

Short term studies show that the sleeve is as effective as the roux-en-Y gastric bypass in terms of weight loss and improvement or remission of diabetes. There is also evidence that suggest the sleeve, similar to the gastric bypass, is effective in improving type 2 diabetes independent of the weight loss. The complication rates of the sleeve fall between those of the adjustable gastric band and the roux-en-y gastric bypass.

Advantages

  1. Restricts the amount of food the stomach can hold
  2. Induces rapid and significant weight loss that comparative studies find similar to that of the Roux-en-Y gastric bypass. Weight loss of >50% for 3-5+ year data, and weight loss comparable to that of the bypass with maintenance of >50%
  3. Requires no foreign objects (AGB), and no bypass or re-routing of the food stream (RYGB)
  4. Involves a relatively short hospital stay of approximately 2 days
  5. Causes favorable changes in gut hormones that suppress hunger, reduce appetite and improve satiety

Disadvantages

  1. Is a non-reversible procedure
  2. Has the potential for long-term vitamin deficiencies
  3. Has a higher early complication rate than the AGB

Gastric Band

The Adjustable Gastric Band – often called the band – involves an inflatable band that is placed around the upper portion of the stomach, creating a small stomach pouch above the band, and the rest of the stomach below the band.

The Procedure

gastric_band

The common explanation of how this device works is that with the smaller stomach pouch, eating just a small amount of food will satisfy hunger and promote the feeling of fullness. The feeling of fullness depends upon the size of the opening between the pouch and the remainder of the stomach created by the gastric band. The size of the stomach opening can be adjusted by filling the band with sterile saline, which is injected through a port placed under the skin.

Reducing the size of the opening is done gradually over time with repeated adjustments or “fills.” The notion that the band is a restrictive procedure (works by restricting how much food can be consumed per meal and by restricting the emptying of the food through the band) has been challenged by studies that show the food passes rather quickly through the band, and that absence of hunger or feeling of being satisfied was not related to food remaining in the pouch above the band. What is known is that there is no malabsorption; the food is digested and absorbed as it would be normally.

The clinical impact of the band seems to be that it reduces hunger, which helps the patients to decrease the amount of calories that are consumed.

Advantages

  1. Reduces the amount of food the stomach can hold
  2. Induces excess weight loss of approximately 40 – 50 percent
  3. Involves no cutting of the stomach or rerouting of the intestines
  4. Requires a shorter hospital stay, usually less than 24 hours, with some centers discharging the patient the same day as surgery
  5. Is reversible and adjustable
  6. Has the lowest rate of early postoperative complications and mortality among the approved bariatric procedures
  7. Has the lowest risk for vitamin/mineral deficiencies

Disadvantages

  1. Slower and less early weight loss than other surgical procedures
  2. Greater percentage of patients failing to lose at least 50 percent of excess body weight compared to the other surgeries commonly performed
  3. Requires a foreign device to remain in the body
  4. Can result in possible band slippage or band erosion into the stomach in a small percentage of patients
  5. Can have mechanical problems with the band, tube or port in a small percentage of patients
  6. Can result in dilation of the gullet if the patient overeats
  7. Requires strict adherence to the postoperative diet and to postoperative follow-up visits
  8. Highest rate of re-operation

How long after metabolic and bariatric surgery will I have to be out from work?

After surgery, most patients return to work in one or two weeks. You will have low energy for a while after surgery and may need to have some half days, or work every other day for your first week back. Your surgeon will give you clear instructions. Most jobs want you back in the workplace as soon as possible, even if you can’t perform ALL duties right away. Your safety and the safety of others are extremely important – low energy can be dangerous in some jobs.

Many patients are worried about getting hernias at incisions. That is almost never a problem from work or lifting. Hernias are more often the result of infection. You will not feel well if you do too much.


When can I start exercising again after surgery?

Right away! You will take gentle, short walks even while you are in the hospital. The key is to start slow. Listen to your body and your surgeon. If you lift weights or do sports, stay “low impact” for the first month (avoid competition, think participation). Build slowly over several weeks. If you swim, your wounds need to be healed over before you get back in the water.


Does type 2 diabetes make surgery riskier?

It can. Be sure to follow any instructions from your surgeon about managing your diabetes around the time of surgery. Almost everyone with Type 2 Diabetes sees big improvement or even complete remission after surgery. Some studies have even reported improvement of Type 1 Diabetes after bariatric procedures.


Can I have laparoscopic surgery if I have heart disease?

Yes, but you may need medical clearance from your cardiologist. Bariatric surgery leads to improvement in most problems related to heart disease including:

  • High Blood Pressure
  • Cholesterol
  • Lipid problems
  • Heart enlargement (dilated heart, or abnormal thickening)
  • Vascular (artery and vein) and coronary (heart artery) disease

During the screening process, be sure to let your surgeon or nurse know about any heart conditions you have. Even those with atrial fibrillation, heart valve replacement, or previous stents or heart bypass surgery usually do very well. If you are on blood thinners of any type, expect special instructions just before and after surgery.


When can I get pregnant after metabolic and bariatric surgery? Will the baby be healthy?

Most women are much more fertile after surgery, even with moderate pre-op weight loss. Birth control pills do NOT work as well in heavy patients. Birth control pills are not very reliable during the time your weight is changing. For this reason, having an IUD or using condoms and spermicide with ALL intercourse is needed. Menstrual periods can be very irregular, and you can get pregnant when you least expect it!

Most groups recommend waiting 12-18 months after surgery before getting pregnant.

Many women who become pregnant after surgery are several years older than their friends were when having kids. Being older when pregnant does mean possible increased risks of certain problems. Down’s syndrome and spinal deformities are two examples. The good news is that, after surgery, there is much less risk of experiencing problems during pregnancy (gestational diabetes, eclampsia, macrosomia) and during childbirth. There are also fewer miscarriages and stillbirths than in heavy women who have not had surgery and weight loss.

Kids born after mom’s surgery are LESS at risk of being affected by obesity later, due to activation of certain genes during fetal growth (look up “epigenetics” – for more information). There is also less risk of needing a C section.


Will I need to have plastic surgery?

Most patients have some loose or sagging skin, but it is often more temporary than expected. You will have a lot of change between 6 and 18 months after surgery. Your individual appearance depends upon several things, including how much weight you lose, your age, your genetics and whether or not you exercise or smoke. Generally, loose skin is well-hidden by clothing. Many patients wear compression garments, which can be found online, to help with appearance.

Some patients will choose to have plastic surgery to remove excess skin. Most surgeons recommend waiting at least 18 months, but you can be evaluated before that. Plastic surgery for removal of excess abdominal and breast skin is often covered by insurance for reasons of moisture, hygiene and rash issues.

Arms and other areas may not be covered if they are considered “purely” cosmetic by your insurer.


Will I lose my hair after bariatric surgery?

Some hair loss is common between 3 and 6 months following surgery. The reasons for this are not totally understood. Even if you take all recommended supplements, hair loss will be noticed until the follicles come back. Hair loss is almost always temporary. Adequate intake of protein, vitamins and minerals will help to ensure hair re-growth, and avoid longer term thinning.


Will I have to take vitamins and minerals after surgery?

You will need to take a multivitamin for life. You may need higher doses of certain vitamins or minerals, especially Iron, Calcium, and Vitamin D. You will also need to have at least yearly blood tests.


Will I have to go on a diet before I have surgery?

Yes. Most bariatric surgeons put their patients on a special pre-operative diet, usually 2 or 3 weeks just before surgery. The reason for the pre-operative diet is to shrink the liver and reduce fat in the abdomen. This helps during the procedure and makes it safer.  These diets are very different from the short term diets, and usually are more about food education and showing a willingness to complete appointments and to learn.


Will I have to diet or exercise after the procedure?

No and Yes.

Most people think of a “diet” as a plan that leaves you hungry. That is not the way people feel after surgery. Eventually, most patients get some form of appetite back 6-18 months after surgery. Your appetite is much weaker, and easier to satisfy than before.

This does not mean that you can eat whatever and whenever you want. Healthier food choices are important to best results, but most patients still enjoy tasty food, and even “treats.”

Most patients also think of exercise as something that must be intense and painful (like “boot camp”). Regular, modest activity is far more useful in the long term. Even elite athletes can’t stay at a “peak” every week of the year. Sometimes exercise is work, but if it becomes a punishing, never-ending battle, you will not keep going. Instead, work with your surgeon’s program to find a variety of activities that can work for you. There is no “one-size-fits-all” plan. Expect to learn and change as you go!

For many patients (and normal weight people, too) exercise is more important for regular stress control, and for appetite control, than simply burning off calories. As we age, inactivity can lead to being frail or fragile, which is quite dangerous to overall health. Healthy bones and avoiding muscle loss partly depends on doing weekly weight bearing (including walking) or muscle resistance (weights or similar) exercise.


Can I go off some of my medications after surgery?

As you lose weight, you may be able to reduce or eliminate the need for many of the medications you take for high blood pressure, heart disease, arthritis, cholesterol, and diabetes. If you have a gastric bypass or sleeve gastrectomy , you may even be able to reduce the dosage or discontinue the use of your diabetes medications soon after your procedure.

Gastric Band Gastric Bypass Gastric Sleeve
gastric band gastric bypass gastric sleeve
How it works

  • Gradually limits food intake
  • Slows food transit
  • Feeling of fullness after a smaller amount of food meaning you eat less
  • Feeling full faster
  • Stay full for longer
How it works

  • Gradually limits food intake
  • Feeling of fullness
  • Limits calorie absorption
How it works

  • Limits food intake
  • Feeling of fullness quicker
  • Reduces hunger sensation
Who might have this surgery?

  • Active patients
  • Good dieters, who cannot maintain their weight loss
  • Someone not prone to snacking on crisps, chocolate, ice cream etc
  • Determined to lose weight by working hard though non-surgical methods e.g. exercise
Who might have this surgery?

  • Someone who has co-morbidities e.g. diabetes, hypertension
  • Need for significant weight loss
  • Someone who is prone to snacking heavily
  • Sweet eaters
  • Someone with irregular meal patterns
Who might have this surgery?

  • Someone on high level of medication
  • Someone who has co-morbidities e.g. diabetes, hypertension
  • Need for significant weight loss
  • Someone who is prone to snacking heavily
  • Someone with irregular meal patterns
Approx. length of procedure

1- 1 ½ hour

*These times do not represent how long you may be in theatre or recovery. They are the approximate length of the procedure itself and vary according to each individual

Approx. length of procedure

2-2 ½ hours

*These times do not represent how long you may be in theatre or recovery. They are the approximate length of the procedure itself and vary according to each individual

Approx. length of procedure

1 ½ – 2 hours

*These times do not represent how long you may be in theatre or recovery. They are the approximate length of the procedure itself and vary according to each individual

Length of hospital stay

Day stay*/ 1 night

*You must agree this with your surgeon prior to your procedure.

Length of hospital stay

2/3 nights

Length of hospital stay

2/3 nights

Expected weight loss

50% excess weight

Expected weight loss

70% excess weight

Expected weight loss

60% excess weight

Reversible

Yes

Reversible

No – revisions possible

Reversible

No

Time off work

1 week

Time off work

2-3 weeks

Time off work

2-3 weeks

Benefits

  • Simple and safe procedure
  • Fast recovery
  • Fully reversible
  • Short stay in hospital
  • Adjustable
Benefits

  • Rapid weight loss
  • Co-morbidities improved e.g. diabetes, hypertension
  • Food control becomes much easier
  • Limited calories absorbed
Benefits

  • Rapid weight loss
  • Reduces hunger -the portion of the stomach that produces Ghrelin (the hunger stimulating hormone) is removed
  • Food intolerances reduced
  • Low malnutrition risk

 

*Weight loss surgery results and benefits vary and are different for every individual

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