Choosing a Bariatric Surgery Procedure

What is bariatric surgery?

Bariatric surgery can help you lose weight. It's a choice for some people who are obese and have not been able to lose weight with other methods. Your healthcare provider might discuss bariatric surgery with you if you are morbidly obese or if you are obese and have an obesity-related health problem. These include diabetes, sleep apnea, asthma, high blood pressure, and arthritis. Diabetes and certain other health problems may get better with weight loss.

There are several different bariatric surgery procedures. The type of bariatric surgery that works best for you will depend on several factors. These include your general health, your health needs, and your own preference.

What types of bariatric surgeries are available?

The most common types of bariatric surgery are sleeve gastrectomy, gastric bypass, and adjustable gastric banding. 

In sleeve gastrectomy, up to 80% of the upper and mid stomach is removed by using a stapling device. This forms the stomach into the shape of a banana. As a result, the sleeve holds much less solid food and liquid. Since you eat much less, you can lose weight after this operation. The amount of "hunger hormone" made by the stomach drops by a lot after the surgery. You may not feel as hungry after this procedure. This operation is the most common bariatric surgery procedure.

During gastric bypass, the surgeon divides the upper part of the stomach with the stapler into a small pouch, about the size of an egg. The small intestine is divided with the stapler and is brought up to the gastric pouch and connected to it with a small opening. The other end of the small intestine, which remains connected to the bypassed larger stomach, is connected to the small intestine several feet downstream from the gastric pouch. This connection looks like a "Y," so this procedure is sometimes called a Roux-en-Y gastric bypass. Because the gastric pouch is small, you will eat much smaller meals. You may feel much less hungry after this surgery during the first year.

During adjustable gastric banding, the surgeon places an adjustable silicone band around the top of your stomach. The size of the opening through the upper stomach is controlled by fluid injections into a port that is placed under the skin of the belly (abdomen). Food travels through the upper stomach and band into the larger, lower stomach, but more slowly than usual because of the small opening through the band. Fluid can also be removed through the port to loosen the band if it's too tight. The band was very popular when first introduced as a surgery. But it is not used nearly as much ow because it usually does not lead to as much weight loss as the other bariatric surgery procedures.

Another less common procedure is the biliopancreatic diversion with duodenal switch (BPD-DS). Most often, it is just called the duodenal switch. It is a more complex operation than the other ones. But it can lead to more weight loss than they do. This procedure starts with a sleeve gastrectomy. The first part of the small intestine (the duodenum) is then divided with the stapler. The sleeve is then attached to a part of the lower small intestine so that much of the small intestine does not have food traveling through it. The sleeve holds much less food, and your body absorbs far fewer calories and nutrients from food.

Surgeons can do most of these types of surgeries as minimally invasive procedures, known as laparoscopic surgery. This type of surgery is done with small incisions, a small camera, and small tools. It's most likely that your surgeon will use a laparoscopic approach for your bariatric surgery. They can also be done laparoscopically using the surgical robot.

Your healthcare provider can go over your individual situation and make recommendations as to which of these procedures might be better for you.

What are the advantages and disadvantages of each type of bariatric surgery?

Lap banding

Lap banding is a simpler surgery than the other procedures. After lap band surgery, it's fairly easy to loosen or tighten the band by putting a needle through the abdomen into the port, but you may need more visits to your healthcare provider for band adjustments. A tighter band might help you feel fuller sooner. This might help you lose weight more quickly. This surgery can help you lose from 30 to 50 pounds. But results vary a lot between different people. You might not lose as much weight as you would like.

Lap banding might not be right for you if you think you'll have a hard time following a nutritional program. For example, if you drink a lot of high-calorie liquids, the lap band likely will not help you lose weight. You might develop heartburn or reflux if the band is tight. The band sometimes slips out of position and can cause an obstruction of the stomach. Some bands have to be removed because of this. Sometimes there can be issues with the band leaking or with the port.

Sleeve gastrectomy

Sleeve gastrectomy is more complex than the band because much of the stomach is removed. Food still travels the same way it did before surgery, and some vitamins like iron and calcium are absorbed almost the same way as before surgery. If you need an upper endoscopy later, the endoscopist can still see the bottom of the stomach and the duodenum. You most likely can still take nonsteroidal anti-inflammatory medicines after this surgery. You may lose from 50 to 80 pounds with a sleeve gastrectomy, if you eat and exercise as you should do.

As time goes by, the sleeve can dilate, or get larger. This means that you could eat more food and gain weight back. Another risk is the onset of heartburn or reflux, which can happen after surgery. You might need to take medicines for this. If you already have heartburn or reflux before surgery, doing a sleeve gastrectomy could make it much worse. If reflux symptoms are severe after a sleeve gastrectomy, it could be revised into a gastric bypass, which generally improves reflux symptoms.

Gastric bypass

Gastric bypass is a more complex surgery than sleeve gastrectomy. It works very well for weight loss, and you can lose up to 100 pounds. It's one of the better procedures to improve or resolve diabetes. It is also a very good operation to resolve heartburn or reflux. The weight loss goes on for about a year, and then it's usual to see some weight regain. It's very important to keep up with eating the right foods and to keep physically active.

You are also more likely to have problems with nutritional deficiency. You will have to take multivitamins, calcium, and vitamin B-12 regularly. You can get ulcers at the bottom of the stomach pouch if you smoke, or if you take nonsteroidal anti-inflammatory medicines on a regular basis. Because the operation is on the small bowel as well, you might get a small bowel obstruction later in life and need surgery for that. If you eat the wrong things like sugars, you might have the dumping syndrome (abdominal cramping and diarrhea). But this syndrome can usually be avoided by eating the right foods. Iron is not absorbed as well after a gastric bypass, and this could produce iron deficiency anemia.

BPD-DS procedure

A BPD-DS procedure (the duodenal switch) may be most helpful for a person who is extremely obese. You can lose up to 150 or 200 pounds. It's likely the best operation for someone with type 2 diabetes. It also can help you keep the weight off for many years. It takes longer to do this operation than the other bariatric surgical procedures. It has a higher risk of some complications than other weight-loss surgery. Because fats are not absorbed very well, if you do eat fatty foods, you may have loose bowel movements or diarrhea. You also need to take more minerals and vitamins than with a gastric bypass. The duodenal switch has a higher risk of nutritional and vitamin deficiencies. You will need to see your healthcare provider periodically to have checkups.

What are the risks of bariatric surgery?

All surgery has risks. Your risks may vary according to your general health, your age, the type of surgery you choose, and the amount of weight you need to lose. Talk with your healthcare provider about the risks that most apply to you. Risks of bariatric surgery include:

• Bleeding

• Infection, including a leak from the staple lines from the stomach or small bowel 

• Blockage of your bowels (intestinal blockage)

• Blood clots in your legs that can travel to your lungs and heart 

• Heart attack

• Need for follow-up surgery

• Gallstones (a later complication), which may require surgery to remove the gallbladder

• Nutritional deficiencies from poor absorption (a later complication)

• Mental health problems after the procedure

• Poor wound healing, including scarring of the incisions, and a hernia at the incisions

• Problems with the band or the port that often need more surgery

• Gastric reflux (more common after a sleeve gastrectomy)

There is also a risk that you might regain weight after you have lost it.

How does surgery compare with medical treatment?

People who get surgery tend to lose much more weight than people who get medical therapy for their weight loss, as long as they follow the recommendations for changes to their diet and physical activity. This also means that surgery is more likely to help improve their health conditions linked to obesity, such as diabetes or sleep apnea. Some people can have modest weight loss with medical therapy alone, but most morbidly obese people won't be able to keep the weight off. Some people don't lose as much weight as they want after surgery, and some people can regain weight after they have lost it after surgery. Medical treatment with weight loss medicine is sometimes used after bariatric surgery to help deal with weight regain.

What should I look for in a bariatric surgery program?

Look for an accredited surgery center with support staff. Support staff should include a dietitian, counselor, and nurses or physician assistants who have had experience in weight loss surgery. Your healthcare provider should be board certified. The center should also provide you with an education program. The program is to help prepare you for before, during, and life after surgery. This is very important to help ensure good results after surgery. The program will likely take several months to prepare you for surgery. And it should provide long-term follow-up after surgery. You may ask what procedures they do, and the results and complications they have had.

How will I need to manage my condition after surgery?

For the rest of your life, you need to work with your healthcare providers to stay healthy. Your weight loss surgical team will keep track of your health, especially as you lose weight quickly in the first 6 months or so after your surgery. Weight loss tends to be at its peak around a year after surgery.

You will get instructions about how to adapt to your new diet after your surgery. You will likely be on liquid nutrition for a few weeks after surgery. Over time, you'll start to eat soft foods and then solid foods. If you eat too much or too quickly, you may have abdominal pain or vomiting. You'll learn how to eat slowly to prevent your new stomach from being too full.

Your healthcare provider will give you more instructions about your diet. These may vary depending on the type of surgery you had. You'll need to learn good habits like choosing healthy foods and not skipping meals. Your healthcare provider or dietitian may also need to screen you for low levels of certain nutrients.

It's important to have sensible goals about what a particular bariatric surgical procedure might achieve for you. Some people having bariatric surgery don't lose as much weight as they would like. Even if you don't lose all your excess weight, medical issues such as diabetes, sleep apnea, and high blood pressure should get better. You may be able to reduce the amount of medicines that you need to take.