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Who is the right candidate for the Bariatric Surgery?

Bariatric surgery is not just a fashion. It's a serious, life changing procedure that is helping thousands of obese patients loses the weight necessary to improve health and lengthen their lives. What does it take to qualify for this surgery? Who should consider it? Who should not?

What is bariatric surgery?

In general, it's surgery that involves the gastrointestinal tract, the stomach, the intestines, and it's meant to enable people to lose weight for long term.

What are the primary procedures involved?

There are probably 20 or 30 operations that have developed over the last 50 years to enable people to lose weight long-term. Over the past say 10-21 Years, three major operations have emerged that have been shown to be both safe and effective. These operations include the gastric bypass, which is also called Roux-en-y gastric bypass.

This operation is currently the most commonly performed procedure. It involves two things that is done to the intestinal track:

• Stapling across the stomach to make a very small stomach pouch, reducing stomach volume by about 95%.
• By bypass a small portion of the upper intestinal tract. The small stomach pouch allows an individual to feel full with a small amount of food and reduces appetite. The bypass also aids weight loss by decreasing the absorption of some of the calories that are eaten.

That's the gastric bypass procedure. The average patient tends to lose about 65% to 75% of the excess weight they're carrying. So the patient that is 100 pounds overweight will typically lose 65 to 70 pounds and keep that weight off long term five, ten, fifteen years and beyond. Patients who have this operation do need vitamin supplements such as iron, B12 and calcium in order to offset deficiencies that could occur after the surgery. The second most common operation for weight loss is called gastric banding. And another term commonly used would be the lap band, which is actually a specific device made by Inamed. A lap band is an adjustable band made of silicon that is placed around the upper stomach. And it, like gastric bypass, creates a small pouch about the size of a walnut. This band is adjustable. It can be adjusted after surgery; it can be made tighter or looser by filling the band with fluid. The band is attached to its tubing -- attached to a reservoir that's placed under the skin of the abdomen. After surgery the doctor can add fluid through the skin and a port to adjust the diameter of the band that will increase weight loss.

How does gastric bypass actually reduce appetite?

Appetite, meaning the desire to eat, is as complex as many other human urges we have. It is known that there is much communication between stomach and intestines and the brain through various pathways. These can be hormonal as well as neurological. It hasn't been quite easy to figure out exactly how these operations work in terms of reducing appetite, but still they are quite effective. Some ideas put forth would suggest that filling the small stomach pouch stretches the small stomach, which sends signals back to the brain, telling the individual that they're full and satisfied. That is known as satiety. if anyone asks any patient who has had gastric bypass, particularly in that first year, they will certainly tell that their appetite is much less, and they will tell that a much smaller quantity of food fills them up and makes them feel satisfied. And that's the key. Many diets result in weight loss but still leave the individual wanting more. These operations are fundamentally different because they satisfy a patient's desires.

About the lap band: Why would physicians want to adjust the size of the pouch?

The advantage to the lap band is that the physicians can adjust the diameter so that it's just right. If the band is made too tight, then patients will have trouble getting any food down. They may have nausea and vomiting. A previous version of gastric banding had a fixed band that would not allow adjusting, meaning the surgeon had to guess the exact diameter that worked best for that patient. A band can also be too loose, then anything flows through it and patients have very minimal weight loss, if any. A lap band's adjustability allows the physician, after the operation, to find the -- and pardon this pun -- the sweet spot that provides the best diameter of the opening to create weight los but not cause undesirable side effects.

Given this adjustability, why is the lap band produce less common than the gastric bypass?

A good way to look at this is that the band has part of the components of the bypass. It has the small stomach component, the pouch, but doesn't have the bypass. So the band is two-thirds as effective as the bypass because it has just the restrictive component of the operation and not the bypass component.

What would happen if you used the restrictive component of a lap band with the bypass portion of the gastric bypass?

These two operations have not commonly been used in combination. However, there are some surgeons beginning to combine them in more of an investigational manner. Right now they are not available in wide use together, but in the future that may be a possibility.

Is there same size pouch for everyone during surgery?

Regarding pouch size, most surgeons try to make the pouch as small as possible for that very reason. A large pouch overtime has a tendency to stretch and patients will consume more food to reach that point of being satisfied. So most surgeons do advocate or create a relatively small pouch -- again, the size of a walnut or in medical terms, approximately 15 milliliters in volume. In general, “the smaller the better”

What happens if someone has the procedure and does overeat with this small pouch?

While overeating may happen within the first few months of surgery, it's quite uncommon after because, again, patients become accustomed to their smaller stomach and their overall desire to eat a large meal is decreased, and they begin to have a strong sense of when they are full, and so they stop eating. Nausea and vomiting may occur perhaps in the first few months. It's rarely a significant issue. After six to nine months after surgery, it is quite rare for patients to overeat.

Is it so that the surgery is not a license to eat?

These two operations cause weight loss principally because fewer calories are consumed in the body. It's called mal-absorption procedure. Unlike the gastric bypass, it involves bypassing most of the intestines so that only a small quantity of calories can be absorbed by the body. So these patients have a much larger stomach and consume quite a large quantity of calories, perhaps even more than 3,400 calories a day, and still lose weight because only a small quantity is absorbed. These mal-absorption operations are very effective. However, these operations have a much higher rate of nutritional deficiencies. These patients often have diarrhea or many loose bowel movements per day, and they may have nutritional deficiencies such as anemia, fat soluble vitamin deficiencies, and protein malnutrition. Some of these patients will require artificial nutrition through their veins for some period to replete their body of these important nutrients. So, the mal-absorption operations allow patients to consume large quantities of calories, but there is a very dramatic decrease in absorption. Most bariatric surgeons do not recommend these operations as a first-line therapy.

Why someone would choose that particular therapy which has many complications?

This kind of weight loss is for people who have severe obesity. It’s all a matter of risk-benefits. The mal-absorption operations are much cruel. They are even more effective than gastric bypass and lap band in terms of weight loss. In fact, these patients tend to lose 80% of their excess weight or more. So in some very, very large patients, perhaps in the four- or five-hundred-pound category, these operations will enable them to get closer to their ideal body weight. But there's a price to pay for that. So there may be a role for these operations for some patients, but probably for the majority who are seeking bariatric surgery the gastric bypass or lap band would be the best options.

Who is a good candidate for weight loss surgery?

First and foremost this kind of weight loss is for people who have severe obesity, which is usually defined as more than 100 pounds of excess body weight. Usually that amount of weight is almost always associated with many other medical conditions, such as diabetes, high blood pressure, sleep apnea, elevated cholesterol, and joint problems with knees, hips, and back. So these operations are for people who have 100 pounds or more of excess weight and medical conditions related to that heavy weight; they're not for patients who want to lose 30 pounds, or people who want to get into a bikini for their vacation.

Will this kind of procedure help with my type 2 diabetes and with getting pregnant?

Patients with severe obesity often have or will develop type 2 diabetes. Diabetes is one of the most common medical conditions attributed to severe obesity. Bariatric surgery very recently has been shown to be extremely effective at not only improving but in the majority of cases completely curing type 2 diabetes. Shows that 83% of patients who had gastric bypass surgery had complete resolution of their diabetes. There was no other more effective long-term therapy for diabetes than bariatric surgery in patients with obesity. So, here one can strongly advocate for bariatric surgery in diabetic patients. Secondly for pregnancy, both the gastric bypass and lap band operations can certainly be performed in young women who want to get pregnant at some time in their life. With the gastric bypass we strongly encourage that for the year following the operation, they take measures not to become pregnant. This is primarily because of the very rapid weight loss that occurs in those first few months after surgery. If a woman were to get pregnant during that time, it would make managing the pregnancy quite challenging, for obvious reasons. But beyond that one year, when the patient's weight has stabilized, becoming pregnant is not a problem. One advantage of the lap band procedure is that it is adjustable, so if a woman were to get pregnant even within a few months after surgery, all the fluid from the band could be removed. She would eat, you know, totally normally as she had before the surgery. And after delivering the baby, the band can be retightened up again. That's one big advantage of the adjustability of the lap band.

Will there be any affect of reduction in nutritional intake with gastric bypass to the breast milk and its value to the baby?

Although it is true that the quantity of food intake after gastric bypass is reduced, it still is very adequate to maintain a normal, healthy weight. Most patients after gastric bypass will consume 1300 to 1500 calories a day and can certainly intake enough protein and nutrients to stay healthy, including breast-feeding.

What time frame are we talking about from surgery to seeing a real effect on type 2 diabetes?

Almost immediate, while leaving the hospital one patient can lose almost one-third blood sugar from the body. So even before there is dramatic weight loss, gastric bypass operation can have dramatic effect. It's quite amazing. And for the other two-thirds the improvement happens over the ensuing months, such that by within a year after the operation for the gastric bypass, almost all patients have resolution of their diabetes. Weight loss of 20 or even 30 pounds per month is not rare. And for the lap band, it's similarly effective.

How much does a pouch stretch over time?

If the pouch is made relatively small initially, there should be minimal stretching. Most surgeons will make a pouch that's quite small, approximately 15 milliliters, or the size of a walnut. So it has minimal capacity to stretch. There can be weight gain, though, after any bariatric operation. And over time, if you follow patients 10, 15, 20 years, some will gain back some weight. On average it's usually about 10% or less. So in other words, if a patient has 100 pounds of excess weight and loses 75 pounds in the first two years, over the next ten years they may gain back ten or fifteen pounds. That's a typical scenario.

Does the age of the patient when they have the initially surgery effect the percentage they're likely to lose and how much they are likely to regain?

There does not appear to be an association between the patient's age and how much weight they lose or the potential for regaining of weight. Many elderly patients can qualify for bariatric surgery. Patients in their 60s and even in their 70s may qualify for surgery if they are in relatively good health to withstand a major operation.

How can one know when he has lost all that he was going to lose?

Within the first few months after gastric bypass there's rapid weight loss. Weight loss on the order of 20 or even 30 pounds per month is not rare. As time goes on, certainly beyond one year after surgery, the weight loss definitely slows down. Most patients will reach their new baseline weight somewhere between one-and-a-half to two years after surgery. This can also be affected by the activity level of the patient. Most bariatric surgeons strongly advocate patients be involved in an exercise program; regular exercise can dramatically add to the weight loss achieved by the gastric bypass. The patient’s weight loss will likely decrease over the next several months, but you can certainly impact your weight loss by actively being involved in a regular exercise program as well as being very judicious on what and how you eat.

How does a doctor decide which procedure is the right one for a patient?

The choice of the operation will differ among bariatric surgeons. Both operations are effective and relatively safe, but there are differences that may be more or less appealing to individuals. Doctor should try to educate the patients and involve them in the decision.

What are the risks involved in these surgeries? 

It is true these operations can have dramatic benefits to patients by decreasing weight, improving their quality of life, and in some cases even improving their life span. However, even though these operations can be done with laparoscopic surgery, they are still major operations, so complications can occur. In the hands of an experienced surgeon and an experienced medical center, these complications can usually be kept at a very low rate. But one must expect that complications are possible when having this surgery, just like any patient who is contemplating heart surgery or other major intestinal surgery or even gallbladder surgery. It's important for the patients to understand that there certainly is a risk, but there's also a significant risk of severe obesity. Severe obesity over time usually results in many severe medical conditions which can be life threatening, such as diabetes. So there's also a risk of death if a patient does not have surgery and allows their severe medical conditions to worsen over time.

What is the overall risk of death from this operation?

Till now, mortality rates of 1% or less are considered reasonable. How does that compare with other major surgery? Well, heart surgery has a mortality rate of 5%. Colon surgery has a mortality rate of 5%. So there are many other major operations with mortality rates much higher than bariatric surgery.

What are recoveries types like for these surgeries?

If the operations are done with laparoscopic technique that is with small incisions most patients have a very rapid recovery. Gastric bypass surgery means usually a two-day stay in the hospital and then approximately two weeks off of work. With the lap band it's even less. One night in the hospital, and then back to work in seven to 10 days

How would I go about finding the right kind of doctor to do this?

Highly recommended for a patient to find out a surgeon and a hospital that has demonstrated a track record with bariatric surgery from long time, it’s a highly specialized field and it's clear that the best results are achieved by surgeons in hospitals that have experience in this field.

What kind of therapy?

For example some patients who already have severe heart disease or severe lung disease as a consequence of obesity may require a stay in an intensive care unit after surgery. That's quite expensive. And if they are in the intensive care unit for several days, that cost goes way up. Some folks require special tests prior to surgery to determine if they are in good enough health to withstand an operation. Some folks will require treatment of their conditions prior to surgery to optimize their health, to make the operation as safe as possible.

How common is abdominal hernia following gastric bypass surgery?

One of the many benefits of the laparoscopic surgery with the small incisions is that the rate of hernia formation is extremely low. Those patients who have open bariatric surgery, that is with a large incision, usually from the breast bone down to near the naval, have a much greater risk of having a hernia. This is because their large weight pulls on the incision, leading to a hernia in approximately 20% of patients. So, two out of ten patients will get a hernia after open surgery. It's fairly common. However, hernia surgery today can be very effective at resolving or curing this hernia.

Can exercise tighten up the excess skin left after surgery, or is it just an inevitable result?

How much excess skin a patient has after weight loss is entirely dependent upon how large they are before surgery. For example, a person that needs to lose 100 pounds after surgery may have only minimal loose skin and may not desire or need to have any plastic surgery. Patients that lose 200 pounds, however, almost always have redundant skin, either in the abdomen or under the arms or around the thighs. Patients that have excess skin certainly qualify for plastic surgery. Essentially a new specialty within plastic surgery has developed as a result of bariatric surgery. But again, the challenge is for patients to get funding for these procedures. Scope of exercise to tighten up excess skin is very less but will keep a person healthy and will be able to maintain sound life.