Weight Loss Surgery Basics
Severe obesity is a chronic condition that is very difficult to treat. For some people, weight loss surgery helps by restricting food intake or interrupting digestive processes. But keep in mind that weight loss surgery is a serious undertaking. You should clearly understand the pros and cons associated with the procedures before making a decision.
In order to understand how weight loss works, you need to first understand how the normal digestive process functions.
Normally, as food moves along the digestive tract, appropriate digestive juices and enzymes arrive at the right place and at the right time to digest and absorb calories and nutrients. After we chew and swallow our food, it moves down the esophagus to the stomach, where a strong acid continues the digestive process. The stomach can hold about 3 pints of food at one time. When the stomach contents move to the duodenum, the first segment of the small intestine, bile and pancreatic juices speed up digestion. Most of the iron and calcium in the foods we eat is absorbed in the duodenum. The jejunum and ileum, the remaining two segments of the nearly 20 feet of small intestine, complete the absorption of almost all calories and nutrients. The food particles that cannot be digested in the small intestine are stored in the large intestine (made up of the ascending colon, transverse colon, descending colon, sigmoid colon and rectum) until eliminated.
Obesity surgery involves making changes to the stomach and/or small intestine.
How Does Weight Loss Surgery Work?
The concept of gastric surgery to control obesity grew out of results of operations for cancer or severe ulcers that removed large portions of the stomach or small intestine.
Because patients undergoing these procedures tended to lose weight after surgery, some doctors began to use such operations to treat severe obesity. The first operation that was widely used for severe obesity was a type of intestinal bypass. This operation, first used 40 years ago, caused weight loss through malabsorption (decreased ability to absorb nutrients from food because the intestines were removed or bypassed).
The idea was that patients could eat large amounts of food, which would be poorly digested or passed along too fast for the body to absorb many calories. The problem with this surgery was that it caused a loss of essential nutrients (malnutrition) and its side effects were unpredictable and sometimes fatal. The original form of the intestinal bypass operation is no longer used.
Surgeons now use other techniques that produce weight loss primarily by limiting how much the stomach can hold. Two types of surgical procedures used to promote weight loss are:
Restrictive surgery: During these procedures the stomach is made smaller. A section of your stomach is removed or closed which limits the amount of food it can hold and causes you to feel full.
Malabsorptive surgery: Most of digestion and absorption takes place in the small intestine. Surgery to this area shortens the length of the small intestine and/or changes where it connects to the stomach, limiting the amount of food that is completely digested or absorbed (causing malabsorption). These surgeries are now performed along with restrictive surgery.
Through food intake restriction, malabsorption, or a combination of both, you can lose weight since less food either goes into your stomach or stays in your small intestine long enough to be digested and absorbed.
Surgical Procedures
Vertical banded gastroplasty (VBG). Surgical staples are used to divide the stomach into two parts. The upper part is small, which limits space for food. Food empties from the upper pouch into the lower pouch through a small opening. A band is put around this opening so it doesn’t stretch. Risks of Vertical banded gastroplasty include wearing away of the band and breakdown of the staple line. In a small number of cases, stomach juices may leak into the abdomen or infection or death from complications may occur.
Laparoscopic gastric banding (Lap-Band). An inflatable band is placed around the upper stomach to create a small pouch and narrow passage into the remainder of the stomach. This limits food consumption and creates an earlier feeling of fullness. Once the band is in place, it is inflated with saline. The band is adjusted over time by increasing or decreasing the amount of salt solution to change the size of the passage. The band is intended for severely obese people — those at least 100 pounds overweight or who are at least twice their ideal body weight — who have failed to lose weight by other methods such as a supervised diet and exercise. The band is intended to remain in place permanently, but it can be removed if necessary. People who get the band will need to diet and exercise in order to maintain their weight loss. Complications may include nausea and vomiting, heartburn, abdominal pain, band slippage, or pouch enlargement.
Roux-en-Y gastric bypass (RGB). The surgeon makes the stomach smaller by using surgical staples to create a small stomach pouch. The pouch is attached to the middle part of a small intestine. Food bypasses the upper part of the small intestine and stomach and goes into the middle part of the small intestine through a small opening. Bypassing the stomach limits the amount of food a person can eat. By bypassing part of the intestine, the amount of calories and nutrients the body absorbs is reduced. The small opening slows down the rate food leaves the pouch. One risk for patients is “dumping syndrome.” This happens when the stomach contents move too rapidly through the small intestine. Symptoms may include nausea, weakness, sweating, faintness, and diarrhea after eating. Side effects include infection, leaking, pulmonary embolism (sudden blockage in a lung artery), gallstones, and nutritional deficiency.
Biliopancreatic diversion (BPD). This procedure is not commonly used in the United States. A large part of the stomach is removed. The amount of food is restricted, in addition to stomach acid production. The small pouch that remains is connected directly to the final segment of the small intestine, completely bypassing other parts of the small intestine. A common channel remains in which bile and pancreatic digestive juices mix prior to entering the colon. Weight loss occurs since most of the calories and nutrients are routed into the colon where they are not absorbed. This procedure is less frequently used than other types of surgery because of the high risk for nutritional deficiencies. A variation of BPD includes a “duodenal switch,” which leaves a larger portion of the stomach intact, including the pyloric valve that regulates the release of stomach contents into the small intestine. It also keeps a small part of the duodenum.
Benefits and Risks of Weight Loss Surgery
Weight loss surgery is a serious undertaking. Before making a decision, talk to your doctor about the following benefits and risks.
Benefits
Weight loss: Immediately following surgery, most patients lose weight rapidly and continue to do so until 18 to 24 months after the procedure. Although most patients then start to regain some of their lost weight, few regain it all.
Obesity-related conditions improve: For example, in one study, blood sugar levels of most obese patients with diabetes returned to normal after surgery. Nearly all patients whose blood sugar levels did not return to normal were older or had diabetes for a long time.
Risks and Side Effects
Vomiting: This is a common risk of restrictive surgery caused by the small stomach being overly stretched by food particles that have not been chewed well.
“Dumping syndrome:” Caused by malabsorptive surgery, this is when stomach contents move too rapidly through the small intestine. Symptoms include nausea, weakness, sweating, faintness and, occasionally, diarrhea after eating, as well as the inability to eat sweets without becoming extremely weak.
Nutritional deficiencies: Patients who have weight-loss surgery may develop nutritional deficiencies such as anemia, osteoporosis, and metabolic bone disease. These deficiencies can be avoided if vitamin and mineral intakes are maintained.
Complications: Some patients who have weight-loss operations require follow-up operations to correct complications. Complications can include abdominal hernias, infections, breakdown of the staple line (used to make the stomach smaller), and stretched stomach outlets (when the stomach returns to its normal size).
Gallstones: More than one-third of obese patients who have gastric surgery develop gallstones. Gallstones are clumps of cholesterol and other matter that form in the gallbladder. During rapid or substantial weight loss a person’s risk of developing gallstones increases. They can be prevented with supplemental bile salts taken for the first six months after surgery.
Need to temporarily avoid pregnancy: Women of childbearing age should avoid pregnancy until their weight becomes stable because rapid weight loss and nutritional deficiencies can harm a developing fetus.
Side effects: These include nausea, vomiting, bloating, diarrhea, excessive sweating, increased gas and dizziness.
Lifestyle changes: Patients with extensive bypasses of the normal digestive process require not only close monitoring, but also life-long diet and exercise modifications and vitamin and mineral supplementation.
Am I a Candidate Weight Loss Surgery?
If you have a body mass index (BMI) of 40 or more — which is about 100 pounds overweight for men and about 80 pounds for women — you are considered severely obese and therefore a candidate for weight loss surgery.
Obesity surgery may also be an option for people with a BMI between 35 and 40 who suffer from obesity-related problems (for example, severe sleep apnea, obesity-related heart disease, or diabetes). For these people, the risk of death from not having the surgery may be greater than the risks from the possible complications from undergoing the procedures.
Keep in mind that as in other treatments for obesity, results may vary. In many cases, patients are required to show proof that their attempts at dietary weight loss have been ineffective before surgery will be approved. A psychological evaluation may be required by doctors to determine your potential response to weight loss and change in body image. Most surgeons require patients to demonstrate serious motivation and a clear understanding of the extensive dietary, exercise, and medical guidelines that must be followed for the remainder of their lives after having weight loss surgery. In addition, studies are performed to assess the health of your heart and hormonal systems. Nutritional counseling is also a must before and after surgery.
For patients who remain severely obese after non-surgical approaches to weight loss have failed, or for patients who have an obesity-related disease, surgery may be an appropriate treatment option. But for most patients, greater efforts toward weight control, such as changes in eating habits, lifestyle changes, and increasing physical activity, are more appropriate. The following questions may help you decide if weight loss surgery is right for you.
Have you tried to lose weight through conventional methods of weight loss: group classes, one-on-one counseling, calorie controlled meal plans, food journals, and exercise?
Are you well informed about the surgical procedure and the effects of treatment?
Are you determined to lose weight and improve your health?
Are you aware of how your life may change after the operation (adjustment to the side effects of the surgery, including dramatically different eating habits)?
Are you aware of the potential for serious complications from the procedure, the associated dietary restrictions, and the slight chance that the procedure will not help you lose weight?
Are you committed to life-long medical follow-up?
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