Now, I am not a bariatric surgeon, but I believe bariatric surgery is a very effective method of weight loss, and I recommend it to patients who have an extreme amount of weight to lose. Before you decide to follow this road, though, you need to be aware of the potential risks and complications, as well as the medical requirements needed to clear you for surgery.
Patients who would qualify for bariatric surgery have a BMI of at least 40, meaning they have at least 100 pounds of excess body weight to lose. Since a higher BMI is associated with risk factors such as hypertension, diabetes, high cholesterol, liver problems, and obstructive sleep apnea, and weight loss surgery can help reduce all these risks, many insurance companies are now willing to pony up.
Bariatric surgery can also be performed in someone with a BMI of 30 or more as long as they have a second condition that would bene t from the procedure. For instance, if you have a BMI of 30, and you are diabetic and have obstructive sleep apnea, you could potentially qualify for the surgery. However, you could rarely walk into the doctor’s office with a BMI of 30 and no other problems and qualify with your insurance company. They simply will not pay for it, since it can run anywhere from $10,000 to $30,000. And since one out of three Americans is obese, insurance companies have to have some qualifications before they will approve the procedure.
If a patient qualifies and decides to move forward with surgery, the surgeon will analyze the patient’s anatomy, risk factors, and liver size. Depending on these factors, the surgeon might recommend one of the following three common procedures.
OPTION 1: ROUX-EN-Y GASTRIC BYPASS
This procedure has been around the longest (over 20 years). With it, the stomach is divided into two pouches: a really small top pouch and a bigger bottom called the body; surgeons divide the stomach by either sewing or stapling. The procedure reduces your stomach to hold about one ounce of food or fluid. Eventually, the stomach will stretch to be able to hold four to six ounces.
This procedure will also divide your small intestine; the surgeon will join the lower piece of the small intestine to the new small top stomach pouch that has just been created. Then the remaining body of the stomach is connected to the remaining part of the small intestine. By doing this, you bypass the part of the small intestine that actually absorbs a lot of the food and its nutrients.
What is accomplished by the procedure is that you get full quickly from very small amounts of food. You also don’t absorb a lot of the calories, fat, or nutrients from what you are eating—they basically run right through.
This method is highly durable, and patients maintain their weight loss for many years afterwards. The weight loss is rapid: patients can lose up to 60–80 percent of their excess body weight in the first year. So if a patient weighed 400 pounds with 200 pounds of excess body weight, he will typically lose around 120–160 pounds during that first year. That is a significant amount of weight loss, and the fact that it is maintainable for years makes this a great method.
There are some drawbacks to the procedure, however. This kind of surgery actually bypasses the part of the gastrointestinal (GI) tract that absorbs a lot of nutrients such as sugars and fats. Patients can therefore develop what we call “dumping syndrome.” In this condition, when the patient eats foods such as simple sugars, processed carbs, or raw fats, their body simply can’t absorb or use it, so it just dumps it straight into the large intestine, causing explosive diarrhea, nausea, vomiting, stomach cramps, and pain. You may also feel sweaty, dizzy, and shaky. Some people get nauseous and weak, and they have palpitations (heart rate goes up). Patients who su er from this syndrome always know where the closest bathrooms are whenever they go out, and it is an uncomfortable way to live the first year after the surgery. Not everyone will experience the same severity of symptoms, but until you train yourself not to eat certain foods, you have to be cautious.
The bright side of the dumping syndrome is that it forces the patient to start eating healthier since they can’t tolerate the unhealthy foods. But because they have bypassed the part of the bowel that absorbs nutrients, they often become deficient in protein and vitamins and have to take lifetime supplements of protein, iron, vitamin B12, and all the things that should have been absorbed from diet by the small intestine. They have to be on daily multivitamins; at first, some require a double dose to make sure they get everything they need. Sometimes, they are given vitamin B12 shots to bypass the GI tract altogether.
It is also important for women who wish to have children to decide if they want to do this procedure before or after they get pregnant. Preparing your body to have a baby can be difficult when you cannot eat certain things or keep food down. Pregnant women are often nauseated anyway, and this procedure can add another degree of nausea on top of it. We always counsel patients about this, but data does show that women can get pregnant after this procedure. In fact, we have found out that, for some, fertility actually increases once excess weight is lost. But it is important to recognize that a person who has undergone this procedure may have a tougher time due to GI issues.
The Roux-en-Y gastric bypass is a very complex and permanent procedure—once the surgeon sews your small intestine to your new smaller stomach, it’s done. No going back. Nowadays, the surgical risk associated with this method is less than 0.002 percent, but you must find a surgeon who produces these numbers. Don’t just go to that new bariatric surgeon in your neighborhood; he might have done only a few cases. You need to go to someone who has done a few hundred cases, preferably a few thousand, in order to be con dent about the outcome. Overall, however, this method is very effective for losing a lot of weight quickly. Patients can typically go home two to three days after surgery and can return to work one to two weeks later if there were no complications.
OPTION 2: GASTRIC SLEEVE
The idea behind this procedure is similar to the Roux-en-Y gastric procedure—the goal is to reduce the size of your stomach so you can only hold so much food. The difference is that this procedure does not distort any anatomy. Instead, surgeons perform a linear staple down the middle of the stomach so that more than half is not useful anymore. The rest remains intact, and food can pass through the normal path.
Unlike with the Roux-en-Y procedure, the body can continue absorbing all of the nutrients, sugars, and fats as before. Patients do not experience the dumping syndrome as a result of the gastric sleeve procedure. The weight loss is a bit more moderate compared to the rapid weight loss of
the Roux-en-Y procedure, however. Patients can expect to lose 40–60 percent of their excess weight in the first year, compared to the 60–80 percent of the other procedure.
The fact that the sleeve does not have many of the same side effects as the Roux-en-Y is a attractive to a lot of patients. The procedure is durable, but it’s newer than the Roux-en-Y, and leakage can occur if some of the staples ever pop out or move. It is a permanent procedure (irreversible) but can also be used as a bridge to other types of bypass in higher risk patients. The cost is similar to the Roux-en-Y gastric procedure and requires the same time in the operating room and similar recovery time. Depending on your BMI, how much weight you need to lose, and how fast you want to get there, this is a procedure to consider. Your surgeon will let you know if you are a good candidate for this method.
OPTION 3: GASTRIC BAND OR ADJUSTABlE GASTRIC BANDING
The gastric band, or adjustable gastric banding procedure, restricts the volume a patient can eat. It is a laparoscopic procedure, meaning that surgeons don’t cut open your stomach. The procedure involves making few small incisions in the abdominal wall to accommodate a small video camera and surgical instruments. The surgeons view the procedure on a separate video monitor to give them a be er view and access to key structures. The band is an inflatable silicone device that works similarly to a rubber band placed around the top portion of your stomach. The resulting stomach is a small stomach pouch similar to that of the Roux-en-Y procedure except that there is no cu ing involved.
The gastric banding procedure is less complicated than the other two procedures, and people like the fact that it is adjustable and reversible. Patients who are considering having children later can adjust it accordingly so they can lose weight when they need to, increase the size of the stomach before getting pregnant, and then reduce it again later. We believe this to be a durable solution, but since it’s a lot newer than the other procedures, we do not have much long-term data to go by.
Patients are often sent home from the hospital within a day of having this procedure and can frequently return to work within a week. However, some people complain that the gastric band does not control their hunger as well as the other two procedures do. Another major complaint with this method is severe nausea and vomiting. Without a doubt, weight loss is slower with this than with the other two methods, but loss is still significant. The exact percentage varies depending on how small your pouch is, your starting weight, etc.; every patient determines how much weight he or she wants to lose, and the surgeon chooses the size of the band depending on those goals. If patients are not meeting the goal, they go in for an adjustment. Adjustments are done without surgery and can take as little as 10 minutes. The process entails a medical professional injecting saline solution into the port and tubing a ached to the band.
QUAlIFYING AND PREPARING FOR SURGERY
Preparing for bariatric surgery is actually a lengthy process, beginning with a long list of qualifications. First, patients must meet the BMI requirement and be between 18 and 65 years old. Bariatric surgery is not for someone who put on 70 pounds in the last six months; rather, it is for someone who has been carrying excess weight for a good two to five years, and it must be documented for insurance companies to consider paying. Sometimes the insurance company requires the primary care doctors to give them the patient’s records showing all of the office visits and weights for the last couple of years.
Insurance companies often put other stipulations on the procedure as well. These might include going on a diet for three to six months in order to document that you can lose some weight on your own. They may require you to lose 10 percent of your body weight before they will approve the procedure. For someone who weighs 300 or 400 pounds, that is hard! We’re talking about 40 pounds here. That alone could take a year to accomplish for many patients, and it may be the reason they give up on the surgery altogether or are disqualified by the insurance company.
Surgeons also have their own recommendations before they will perform the procedure. They might tell the patient that he must shrink his liver before surgery because the liver is too large due to fat and may be covering the operation site. To shrink the liver, doctors will put the patient on a two-week liquid diet. We talked about how hard liquid diets are; some patients feel as if they are going to die in those two weeks, and some will decide they cannot do it. You also have to stop smoking. Smoking can cause poor healing, so we encourage patients to quit six months before they go into surgery.
When you think of doing bariatric surgery, know that it might be a whole year before you even qualify. It’s not as if you can wake up one day and decide, “Oh, I’m 100 pounds overweight—I’m going to see my surgeon!” You have to plan ahead. It takes time before the insurance company will qualify you and more time before you find the surgeon with whom you feel comfortable. You have to do your own research. Then there is medical clearance, which means you might have to undergo stress tests that make sure your heart will withstand the procedure. There is also a battery of pre-op tests that check things like vitamin levels and the thyroid; and you may need an ultrasound, endoscopy, bone scan, blood checks, X-rays, and other procedures before you’ll be given the green light. On top of that, be prepared to see a dietician, a social worker, a psychiatrist for counseling, the nurse, the surgeon, and a primary care doctor in order to coordinate everything that’s needed. All this before the surgery! Exhausting to think about, isn’t it?
I will tell you this: bariatric surgery is not a process for the weak. You have to focus on the fact that you really want this—your health and your life depend on its success. There are also support groups for bariatric surgery, both within bariatric centers and online. Patients often find that support is crucial to getting through the intense waiting period of qualification and preparation.
COMPlICATIONS AND lIFE AFTER BARIATRIC SURGERY
Patients who undergo bariatric surgery must adopt a whole new way of life. They’ll eat a very specific, modified diet and will require supplements. They’ll need to exercise to strengthen joints and muscles. They must avoid anti-inflammatory medicines like Ibuprofen, aspirin or Aleve, which can cause stomach ulcers. They must avoid taking diuretics, because it can cause electrolyte problems—and if a patient is already not getting enough electrolytes because of the new diet, she doesn’t want to take a medicine that is now going to deplete the little she does have.
Once you undergo bariatric surgery, you are married to your surgeon—so make sure you find one you like! You’ll see him or her at least five or six times per year for two years to make sure there are no complications, and then less after that. If you opt for gastric banding, you see your surgeon even more often, because they sometimes need to adjust the band to help you lost weight faster or slower.
After any bariatric procedure, it’s often a shock for patients to discover how little food or fluid their new stomach can hold. Exactly how much is one ounce? Two or three French fries can ll up a stomach that size, so when we say you cut back on the amount of food you can eat, we really mean it! It will change the way you eat for the rest of your life. You cannot eat and drink at the same time. You must plan ahead since your stomach can only hold a small amount. A patient who is constantly eating may be lucky to consume around 800–1,000 calories a day. Most will never be able to return to a 2,000-calorie diet.
Though the calorie count is low, we don’t believe your body goes into starvation mode (burning muscle for energy) after these surgeries. We don’t see the visual symptoms that go along with this condition, unless the patient is not consistently taking protein and vitamin supplements. Also, once you have these procedures done, you are no longer on a diet that is restricting you from eating; you can munch every two hours if you want to. You just can’t gorge on an entire plate of food anymore. It won’t go down.
Keep in mind that bariatric procedures aiding weight loss also lead to be er health. Diabetes often improves or disappears, and blood pressure and cholesterol lower. For some, sleep apnea improves, arthritis pain lessens, and stress urinary incontinence gets better. For those who have been taking 10 different medications a day for obesity-related conditions, these weight loss procedures can be a miracle. That’s why more insurance companies are falling in line to pay (albeit after the qualification process)—because they see the bene t for patients over a lifetime and know they can ultimately save money by treating them with this one surgery.
The complications arising from these surgeries, however, are not small. There are immediate complications as well as long-term complications. Immediate complications include tissue injury—while the surgeon is in there snipping, stapling, and sewing, he can accidentally poke through the liver, spleen, stomach, esophagus, pancreas, blood vessels, or nerves. There is risk of infection every time your skin is cut into, as well as risk of bleeding or needing transfusions, heart impact from the surgery and anesthesia, and/or organ failure. Things happen. Going to a good surgeon in a center of excellence known for these procedures helps reduce some of these risks.
Things like bowel obstruction can also happen because the bowels are moved during surgery. The bowels are a really long tube, and it is all wrapped in there neatly and nicely. When we go in and move things around, putting objects where they weren’t before, obstruction can develop if bowels get twisted on themselves. Bowel obstruction causes severe nausea, vomiting, and abdominal pain. Often, patients can’t hold anything down, and they have to be admitted to the hospital to prevent dehydration.
Sometimes, the small pouch that was created by the surgery suffers even further narrowing. When we cut through the bowel, inflammation happens, and the body tries to heal. The inflammation can make the pouch narrower or smaller, causing reflux, nausea, and other related symptoms. Stomach ulcers have also been reported, so many patients are placed on medications to prevent this.
Gallstone formation is a common complication of bariatric surgery due to rapid fat loss. Excess bile acids are made to try to break down the fat, but huge quantities just end up forming gallstones, which causes obstruction of the ducts, severe abdominal pain, and infection. Many surgeons now simply plan to take the gallbladder out while they are in the operating room for the weight loss surgery to help avoid this common complication.
Patients can also su er from inflammation called gout. This causes pain in joints such as the big toe, knees, elbow, and wrist. It is due to increased uric acid levels during rapid weight loss.
Other complications can include leakage from stitched and stapled sites. (We call those anastomotic leaks). This may be because you need an extra stitch somewhere, something got stretched, or a staple fell out. Your surgeon will repair this if found.
Sometimes, with the gastric band surgery, the band can slip or erode into the stomach, allowing the stomach to become large again. There have also been a few cases of allergic reaction to the band material since the body can always react negatively to any foreign material, no ma er how good or durable the material is.
Another common and actually expected complication of bariatric surgery is loose skin; you lose weight rapidly and are left with areas of loose skin. Many patients end up needing a second surgery—usually on the excess skin around the stomach area called pannus. Resection is cosmetic, similar to a tummy tuck. Depending on its size, cutting it out can help a patient drop up to another 10 pounds.
Psychosocial issues are another post-surgery complication. Many patients have been dealing with issues stemming from obesity for a long time. Now, when they rapidly lose all that weight, depression can be even more severe. Self-image issues don’t away go away with surgery either. They might experience hair loss and have a hard time adapting. For some patients, the issues that caused the weight gain in the first place, such as emotional eating, still have to be dealt with, and because they can no longer use food as comfort, we’ll see patients trading addictions; instead of food, they reach for cigarettes or alcohol. The divorce rate is also relatively higher in the post-bariatric weight loss patients than in the general population. Patients are dealing with complex emotions—Johnny accepted her the way she was before, but now that she’s lost weight, she’s too good for him. Tension is created in relationships, and patients need help to work through it. These are some of the reasons patients must go through a psychosocial evaluation from a psychiatrist prior to surgery.
Follow-ups are also required and extremely important. To be a successful lifetime bariatric patient, you have to be compliant. You have to take your meds, follow up with your appointments, and let your surgeon know if you’re experiencing any complications. You must be proactive and involved with your doctors so that anything I’ve listed can be caught early and taken care of.
A Better Alternative To Bariatric Surgery in San Antonio
Despite the fear factor of these cautions, everything goes the way that textbooks say it should with 85 percent of bariatric surgery patients. Another 10 to 15 percent have transient problems—maybe a little leakage or some nausea, vomiting or diarrhea. Another one percent will have severe complications, where they experience serious health problems or even death. Patients should be aware of this when considering bariatric weight loss options because there is not a guaranteed smooth course for everyone. Before you opt for bariatric surgery in San Antonio, TX, make sure you’ve put in your best effort and you’ve tried everything … including my secret weapon.
Remember that Bariatric Surgery is effective for extreme cases, and you must go to your San Antonio Weight Loss Clinic for a complimentary consultation to see what kind of process can best give you the results your body needs.
Here’s a short video on the risks of bariatric surgery