Gastrointestinal surgery for obesity, also called bariatric surgery, alters the digestive process so as to achieve rapid weight loss. The operations can be divided into three types: restrictive, malabsorptive, and combined restrictive/malabsorptive. Restrictive weight loss surgeries limit food intake by creating a narrow passage from the upper part of the stomach into the larger lower part, reducing the amount of food the stomach can hold and slowing the passage of food through the stomach. Malabsorptive weight loss surgeries do not limit food intake, but instead exclude most of the small intestine from the digestive tract so fewer calories and nutrients are absorbed. Malabsorptive weight loss surgeries, also called intestinal bypasses, are no longer recommended because they result in severe nutritional deficiencies. Combined operations use stomach restriction and a partial bypass of the small intestine.

Am I a Candidate for obesity Surgery?

You may be a candidate for weight loss surgery if you have:

a body mass index (BMI) of 40 or more about 100 pounds overweight for men and 80 pounds for women (see BMI chart)
a BMI between 35 and 39.9 and a serious obesity-related health problem such as type 2 diabetes, heart disease, or severe sleep apnea (when breathing stops for short periods during sleep)
an understanding of the operation and the lifestyle changes you will need to make.

Is obesity surgery for You?

Bariatric weight loss surgery may be the next step for people who remain severely obese after trying nonsurgical approaches, or for people who have an obesity-related disease. Surgery to produce quick weight loss is a serious undertaking. Anyone thinking about undergoing this type of weight loss surgery should understand what it involves. Answers to the following questions may help you decide whether weight loss surgery is right for you.

Are you:

Unlikely to lose weight or keep weight off long-term with nonsurgical measures?
Well informed about the surgical procedure and the effects of the weight loss surgery?
Determined to lose weight and improve your health?
Aware of how your life may change after the operation (adjustment to the side effects of the operation, including the need to chew food well and inability to eat large meals)?
Aware of the potential for serious complications, dietary restrictions, and occasional failures related to weight loss surgery?
Committed to lifelong medical follow-up and vitamin/mineral supplementation?

Remember: There are no guarantees for any method, including surgery, to produce rapid weight loss and maintain it. Success with weight loss surgery is possible only with maximum cooperation and commitment to behavioral change and medical follow-up and this cooperation and commitment must be carried out for the rest of your life.

A decision to have bariatric surgery is very personal and very important. It will change your life in an irreversible way for the most part, not just because of the quick weight loss it produces. Being careful with a decision like this is the right thing to do. You should research the various weight loss surgeries and the various surgeons. Then you and the surgeon should, together, agree that weight loss surgery is the best choice you can make.

Considerations prior to weight loss surgery:

Can you comply with the therapy and follow up that is so necessary after weight loss surgery?

You have to follow the directions of your surgeon, especially diet, exercise, labs and office follow up. The surgery is a tool only. Rapid weight loss and maintenance depends on your use of this tool. It would be disastrous if one depends on the surgery alone to take care of the obesity. There will never be a break in following the guidelines set forth by your surgeon regarding diet, exercise and follow up. You are making a life-long commitment.

Are you considering weight loss surgery for the right reasons? Do you just want to look better?

Bariatric surgery is NOT done for cosmetic reasons. It is always done to improve failing health. If you meet the medical criteria, you are considering weight loss surgery for health reasons. Feeling better is the goal, looking better is a nice side effect.

Have you made many attempts at weight loss?

Only you can decide if you have reached the point where you have exhausted all other options to lose weight. You are making a serious decision that only YOU can make, once you feel you are well informed about the risks and benefits of weight loss surgery.

Are you comfortable with your decision? Are you apprehensive?

Once you are feeling comfortable with your decision to make a lifestyle change forever and you know you can do it, you are ready. If you know exactly and feel comfortable with how the weight loss surgery rearranges your digestive system and the short and long-term risks of bariatric surgery, you are ready. If you have found a surgeon that you feel very comfortable with, you are ready. If you are apprehensive about the whole process, you are normal!

Types of Weight Loss Surgeries
There are several types of restrictive and combined operations that lead to rapid weight loss. Each one has its own benefits and risks.

Restrictive Weight Loss Surgeries

Purely restrictive operations only limit food intake and do not interfere with the normal digestive process. To perform the operation, doctors create a small pouch at the top of the stomach where food enters from the esophagus. At first, the pouch holds about 1 ounce of food and later may stretch to 2-3 ounces. The lower outlet of the pouch is usually about � inch in diameter or smaller. This small outlet delays the emptying of food from the pouch into the larger part of the stomach and causes a feeling of fullness, thus resulting in rapid weight loss in most patients.

After the operation, patients can no longer eat large amounts of food at one time. Most patients can eat about � to 1 cup of food without discomfort or nausea, but the food has to be soft, moist, and well chewed. Patients who undergo restrictive procedures generally are not able to eat as much as those who have combined operations.

1. Adjustable Gastric Banding (also known as the LAP-BAND) In this procedure, a hollow band made of silicone rubber is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the rest of the stomach. The band is then inflated with a salt solution through a tube that connects the band to an access port placed under the skin. It can be tightened or loosened over time to change the size of the passage by increasing or decreasing the amount of salt solution.

Advantages of this weight loss surgery:

Simple and relatively safe
Short recovery period
Major complication rate is low
No removal of any part of the stomach or intestines
No altering of the natural anatomy
Very short recovery periods

Disadvantages of this weight loss surgery:

About 5% failure rate because of
- Balloon leakage
- Band erosion/migration
- Deep infection
Identifying patients who will not eat through the operation is difficult

2. Vertical Sleeve Gastrectomy (also called vertical Sleeve Gastrectomy, Greater Curvature Gastrectomy, Parietal Gastrectomy, Gastric Reduction and even Vertical Gastroplasty) is performed by approximately 15 surgeons worldwide. The originally procedure, conceived by Dr. D Johnston in England, was called The Magenstrasse and Mill Operation. It generates rapid weight loss by restricting the amount of food that can be eaten (removal of stomach or vertical gastrectomy) without any bypass of the intestines or malabsorption. The stomach pouch is usually made smaller than the pouch used in the Duodenal Switch.

Advantages of this weight loss surgery:

Stomach volume is reduced, but it tends to function normally so most food items can be consumed in small amounts.
Eliminates the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin).
No dumping syndrome because the pylorus is preserved.
Minimizes the chance of an ulcer occurring.
By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are almost eliminated.
Very effective as a first stage procedure for high BMI patients (BMI >55 kg/m2).
Limited results appear promising as a single stage procedure for low BMI patients (BMI 35-45 kg/m2).
Appealing option for people with existing anemia, Crohn's disease and numerous other conditions that make them too high risk for intestinal bypass procedures.
Can be done laparoscopically in patients weighing more than 500 pounds

Disadvantages of this weight loss surgery:

Potential for inadequate weight loss or weight regain. While true for all procedures, it is theoretically more possible with procedures without intestinal bypass.
Higher BMI patients will may need to have a second stage procedure later to help lose all of their excess weight. Two stages may ultimately be safer and more effective than one operation for high BMI patients. This is an active point of discussion for bariatric surgeons.
Soft calories from ice cream, milk shakes, etc., can be absorbed and may slow weight loss.
This procedure does involve stomach stapling and therefore leaks and other complications related to stapling may occur.
Because the stomach is removed, it is not reversible. It can be converted to almost any other weight loss procedure.
Considered investigational by some surgeons and insurance companies.

Combined Restrictive/Malabsorptive Weight Loss Surgeries

Combined operations are the most common bariatric procedures. They restrict both food intake and the amount of calories and nutrients the body absorbs.

1. Roux-en-Y Gastric Bypass (RGB) This operation is the most common and successful combined weight loss surgery in the United States. First, the surgeon creates a small stomach pouch to restrict food intake. Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum (the first segment of the small intestine), and the first portion of the jejunum (the second segment of the small intestine). This reduces the amount of calories and nutrients the body absorbs. Rarely, a cholecystectomy (gall bladder removal) is performed to avoid the gallstones that may result from rapid weight loss. More commonly, patients take medication after the operation to dissolve gallstones.

Advantages of this weight loss surgery:

greatly controls food intake, leading to rapid weight loss
dumping syndrome dumping conditions to control intake of sweets
reversible in an emergency though this procedure should be thought of as a permanent

Disadvantages of this weight loss surgery:

staple line failure
ulcers
narrowing/blockage of the stoma
vomiting if food is not properly chewed or if food is eaten to quickly
weight re-gain is known to happen if dietary changes are not followed long term

2. Duodenal Switch (also called vertical gastrectomy with duodenal switch, biliopancreatic diversion with duodenal switch, DS or BPD-DS) is performed by approximately 50 surgeons worldwide. It generates weight loss by restricting the amount of food that can be eaten (partial gastrectomy (i.e., partial removal of the stomach along the outer curvature see diagram) and by limiting the amount of food (specifically fat) that is absorbed into the body (intestinal bypass or duodenal switch). This weight loss surgery is more controversial because it has a significant component of malabsorption (bypass of the intestinal tract), which seems to augment and help maintain long-term weight loss. Of the procedures currently performed for the treatment of obesity, it has some powerful and effective components. Due to concerns of possible long-term effects of malabsorption and the technical difficulty involved with this type of weight loss surgery, many surgeons don't perform it.

Advantages of this weight loss surgery:

More normal stomach allows for better eating quality, drink with meals
No dumping syndrome because the pylorus is preserved
Minimizes ulcer risk
Very effective for high BMI patients (BMI>55 kg/m2), but can be done on lower BMI just as effectively
The intestinal bypass is partially reversible for those having malabsorptive complications
Laparoscopic approach is offered by some surgeons

Disadvantages of this weight loss surgery:

Chance of chronic diarrhea, possibly more foul smelling stools and gas. This can be due to dieting intake, but for the most part controlled.
Malabsorption can lead to anemia, protein deficiency and metabolic bone disease in up to 5 percent of patients
Carbohydrates can be well absorbed and if eaten in significant quantities lead to inadequate weight loss
This procedure is the most complex surgical weight loss procedure. As with any of the surgeries listed complications can occur in high risk patients (heart failure, sleep apnea)

3. Biliopancreatic Diversion (BPD) In this more complicated combined weight loss surgery, the lower portion of the stomach is removed. The small pouch that remains is connected directly to the final segment of the small intestine, completely bypassing the duodenum and the jejunum. Although this procedure leads to weight loss, it is used less often than other types of operations because of the high risk for nutritional deficiencies. This surgery is not commonly done anymore.

Advantages of this weight loss surgery:

significant malabsorptive component
better chance of sustained weight loss
ability to eat larger quantities of food and still loose weight

Disadvantages of this weight loss surgery:

greater chance of chronic diarrhea, stomal ulcers, more foul smelling stools and flatus
higher risk of nutritional deficiencies
higher chance of micro-nutrient deficiencies such as vitamins and calcium

Advantages/Disadvantages Overview

Advantages: Most patients lose weight quickly and continue to lose for 18 to 24 months after the procedure. With the Roux-en-Y gastric bypass, many patients maintain a weight loss of 60 to 70 percent of their excess weight for 10 years or more. With BPD/DS, most studies report an average weight loss of 75 to 80 percent of excess weight. Because combined operations result in greater weight loss than restrictive operations, they may also be more effective in improving the health problems associated with severe obesity, such as hypertension (high blood pressure), sleep apnea, type 2 diabetes, and osteoarthritis.

Disadvantages: Combined procedures are more difficult to perform than the restrictive procedures. Such weight loss surgeries are also more likely to result in long-term nutritional deficiencies. This is because these weight loss surgeries causes food to bypass the duodenum and jejunum, where most iron and calcium are absorbed.

Laparoscopic Bariatric Surgery

In laparoscopy, the surgeon makes one or more small incisions through which slender surgical instruments are passed. This technique eliminates the need for a large incision and creates less tissue damage. Patients who are super-obese (more than 350 pounds) or have had previous abdominal operations may not be good candidates for laparoscopy, however. Adjustable gastric banding is routinely performed via laparoscopy.

This technique is often used for Roux-en-Y gastric bypass, and although less common, biliopancreatic diversion can also be performed laparoscopically. The small incisions result in less blood loss, shorter hospitalization, a faster recovery, and fewer complications than open operations. However, combined laparoscopic procedures are more difficult to perform than open procedures and can create serious problems if done incorrectly.

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