You eat healthy and exercise regularly but struggle to lose excess weight that is causing health problems. You’ve talked to your doctor, and she agrees: Weight-loss surgery—also called bariatric surgery—may be for you. Now what?
If you have a body mass index (BMI) of 35 to 39.9 with a history of obesity-related conditions such as high blood pressure, type 2 diabetes, infertility, high cholesterol or sleep apnea, or a BMI of at least 40, regardless of any obesity-related diseases, you may be a candidate for weight-loss surgery, according to guidelines set by the National Institutes of Health.
“Weight-loss surgery is a safe approach if you can’t lose weight any other way, as morbid obesity affects quality of life and longevity,” says UNC Medical Center bariatric surgeon Timothy Farrell, MD.
Weight-loss surgery can reduce the impact of comorbidities, other chronic conditions besides the obesity, he explains.
“Patients have their diabetes go into remission, they come off medications for blood pressure and get off their sleep apnea device. It helps fertility for people with polycystic ovarian disease,” or PCOS, Dr. Farrell says. “The desired outcomes from bariatric surgery are not just about weight loss.”
There are three minimally invasive procedures for surgical weight loss: gastric sleeve, gastric bypass and duodenal switch.
“When it comes to choosing the right operation for each patient, we look at how much weight the patient needs to lose to get down to a healthy weight, discuss the medical problems that need to be addressed and look at other quality-of-life goals,” says UNC REX bariatric surgeon Lindsey Sharp, MD. “The reason we have different options is because the procedures work differently.”
The procedures work in two ways: restrictive and malabsorptive. Restrictive procedures reduce the amount of food you can hold in your stomach, making you feel full faster. Malabsorptive procedures change your digestive tract so you process fewer calories. In some cases, both methods are combined to effect greater change. To help ensure nutrition, bariatric patients are put on vitamins.
Restrictive procedures create a small stomach pouch to make you feel fuller faster.
“We alter the size of the stomach by stapling, so we’re making your meal smaller,” Dr. Farrell says. The amount you can eat is reduced.
The most common type of restrictive procedure is the laparoscopic sleeve gastrectomy, Dr. Farrell says. Laparoscopic surgery is a specialized technique that uses smaller incisions than traditional open surgery. In a laparoscopic sleeve gastrectomy, surgeons remove 80 to 85 percent of the stomach, leaving behind a portion that is a narrow tube.
Normally about the size of a football, the stomach is reduced to the size of a banana. When you can’t eat nearly as much food, you lose weight. Dr. Farrell says patients usually lose about 60 percent of excess body weight in the 12 to 18 months after the procedure.
“Folks who have lower BMIs tend to do better with this procedure because the average weight loss is 60 to 80 pounds,” Dr. Sharp says. People who need to lose more than that or who struggle to control their eating might be better served by a different option.
Gastric bypass combines the restrictive and malabsorptive approach. A surgeon creates a small stomach pouch and then constructs a “bypass” for food. The bypass allows food to skip parts of the small intestine, so the body cannot absorb as many calories or nutrients.
“People with a bypass eat smaller meals, and what they eat goes quickly into the intestine. If they cannot self-regulate sugar intake, they will have dumping syndrome, which is marked by intestinal symptoms followed by feelings of low blood sugar for over an hour. Those effects are a strong motivation to avoid carbohydrate-rich drinks and foods and overeating,” Dr. Farrell says.
Gastric bypass can be done laparoscopically or as an open procedure through an upper abdominal incision. Patients usually lose 70 percent of their excess body weight with gastric bypass.
“It’s more effective than the sleeve as far as weight loss and control of certain comorbidities such as diabetes,” Dr. Farrell says.
In fact, 60 to 70 percent of patients with type 2 diabetes have their disease go into remission after gastric bypass, Dr. Sharp says. The procedure is also good for patients with severe acid reflux. However, this procedure comes with more risk factors than the gastric sleeve.
“Patients are at risk for ulcers, bowel obstruction and internal hernias,” Dr. Farrell says.
In addition, because a portion of their intestine isn’t absorbing as well, patients will be more dependent on vitamin supplementation.
Biliopancreatic Diversion with Duodenal Switch
Duodenal switch is a combination of the sleeve and bypass methods.
The procedure starts with the sleeve gastrectomy surgery on the stomach. Then surgeons add an intestinal bypass on the bottom of it, so it gives the sleeve more impact.
“This operation works great for people who want to lose a lot of weight, but it’s also a very modifiable operation if we don’t need to lose as much weight but we want its benefits in terms of getting rid of high cholesterol, high blood pressure and diabetes,” Dr. Sharp says.
The duodenal switch is the most successful procedure for patients with diabetes; 98 percent will see an improvement, Dr. Sharp says.
“About 90 percent of patients with type 2 diabetes can come off their medicine with the duodenal switch,” he says. “It’s a very versatile procedure.”
Dr. Farrell says the switch has some of the same risks as the bypass.
None of these procedures works in isolation. Long-term success requires a lot from patients in terms of lifestyle changes, Dr. Sharp says. They must comply with diet restrictions and exercise regularly.
“All operations are a tool in trying to reset the situation. But you have to follow the program, have support and take your vitamins,” Dr. Farrell says.
To help patients stay committed to making lifestyle and diet changes, Dr. Farrell’s and Dr. Sharp’s practices see patients for follow-up visits for at least five years after the operation. The doctors also encourage patients to join support groups because peer assistance helps in getting past difficult times.