Bariatric Surgery 101

I get so tired of reading about and listening to peoples opinions on what bariatric surgery is, how it works and why people get it from people that have absolutely no idea what they are talking about. I don't know why it bothers me so much, I probably shouldn't let it, but it does. I get so sick of people talking about how "it's the easy way" and it's "cheating". Or that people with bariatric surgery don't put in the work.

Remember, most of what is below I did not write myself. I have sighted my sources at the bottom of the page.

As a treatment for severe obesity, weight loss surgery's popularity is growing. When diet and exercise fail the more than 60 million Americans considered obese, surgery, for some, can literally be lifesaving.

But it isn't for everyone. While generally safe, bariatric weight loss surgery (also called simply weight loss surgery) has risks. And losing weight after bariatric surgery is far from automatic; it takes commitment to lifelong changes in eating patterns and lifestyle.

Gastric bypass surgery is a type of bariatric surgery performed to help morbidly obese patients lose significant amounts of weight—without gaining it back. It is considered the "golden standard" for obesity surgery, with a success rate of over 80%. Most patients lose at least half of their excess weight and keep it off for more than five years, as long as they adhere to an active and healthy lifestyle after surgery.

Gastric bypass helps patients lose weight by restricting food intake and altering the digestive process. This is done by creating a small pouch that serves as the new stomach and bypasses a part of the small intestine. There are several different types of gastric bypass procedures, but the most popular is the Roux-en-Y procedure, which involves stapling the stomach and shaping the small intestine into a “Y” shape.

Two ways that surgical procedures promote weight loss are:

• By decreasing food intake (restriction). Gastric banding, gastric bypass, and vertical-banded gastroplasty are surgeries that limit the amount of food the stomach can hold by closing off or removing parts of the stomach. These operations also delay emptying of the stomach (gastric pouch).
• By causing food to be poorly digested and absorbed (malabsorption). In the gastric bypass procedures, a surgeon makes a direct connection from the stomach to a lower segment of the small intestine, bypassing the duodenum, and some of the jejunum.

In addition to the significant weight loss results this procedure often provides, gastric bypass may also help to:

• Lower blood pressure
• Lower blood sugar
• Decrease workload of the heart
• Lower cholesterol levels

The ideal candidate for gastric bypass surgery is someone who:

• Is at least 18 years old
• Has a BMI of 40 or higher (or 35 or higher with a related medical condition)
• Obstructive sleep apnea, severe arthritis, and diabetes are several conditions that may benefit from even a small weight loss. Weight loss surgery can dramatically reverse these health problems when caused by obesity
• Has been obese for at least five years
• Has tried other methods of weight loss with little to no success
• Is committed to changing his/her lifestyle by eating healthy and exercising regularly after surgery

Here is a list of the most common types of bariatric surgery: 

In Gastric Bypass surgery, part of the stomach is stapled and becomes unusable. Then the smaller portion of the stomach is connected to the intestine. Because their stomachs have a smaller capacity for food, patients who have a gastric bypass will not be inclined to eat as much as they did prior to their surgery; when they do eat, they feel full much sooner than previously. 

During the gastric bypass procedure, your surgeon uses suture-like staples to create a pouch in the top of the stomach. The pouch is then connected directly to a section of the stomach called the Roux limb. The smaller stomach pouch restricts the amount of food that can be digested at any time and limits the body's ability to absorb fat from food by bypassing the majority of the stomach and some of the large intestine. This combination of restrictiveand malabsorptive techniques makes the Roux-en-Y procedure one of the most successful gastric bypass surgeries.

The Adjustable Gastric Band, also known as the Lap-Band, is actually a band that is surgically inserted around the top part of the stomach to create a small pouch in the upper stomach. This procedure decreases the stomach’s capacity to take in food, and also reduces the patient’s desire for food. 

Vertical Banded Gastroplasty (VBG) is like other types of bariatric surgery, in that is separates the stomach into two parts, producing a smaller stomach area within the larger stomach. This procedure also restricts the food intake of the patient. Vertical Banded Gastroplasty also uses staples to make a “smaller stomach” in the upper part of the stomach. 

The advantage of gastric sleeve surgery include:

• 30 to 60% extra weight loss within the first 12 months of the procedure
• Less invasive than gastric bypass
• No cutting or, disconnection or alteration of the intestines
• No risk of “dumping syndrome” typically associated with gastric bypass
• No need for implementation of foreign devices in to the body such as a gastric band
• Less restrictive post-surgery diet
• Procedure may be followed by gastric bypass or duodenal switch for even better results for super obese patients (those with a BMI > 70)
• Can be performed laparoscopically on extremely obese patients

Disadvantages of the Gastric Sleeve

• As with any medical procedure of this nature, there is always the potential for adverse affects. The biggest potential drawback for some people with this procedure is that is irreversible and thus you must really understand all of the implications before proceeding with gastric sleeve surgery.

In addition the following potential drawbacks should be taken in to consideration:

• Since the gastric sleeve is a restrictive weight loss procedure and not malabsorptive, inadequate weight loss or weight regain is more likely to occur than would in a procedure involving intestinal bypass
• The newly created pouch has the potential to stretch over time
• Weight Loss only really noticeable with total change in diet combined with exercise
• Additional surgery may be required for follow-up procedures to combine methods
• Leakage may occur at the site of stapling
• Still no knowledge of long term results due to short history of procedure
• Insurance may not cover due to the short history of the procedure making the cost potentially prohibitive for many people.

The Fobi-Pouch is very similar to the gastric bypass surgery. This procedure is typically done on overweight patients who have had the vertical banded gastroplasty but have not lost a sufficient amount of weight.

The Roux-en-Y Gastric Bypass is a form of gastric bypass surgery that separates the stomach into two parts. A smaller stomach pouch is created and connected to the intestine. Because a large part of the stomach is bypassed, food intake and fat absorption are both significantly reduced. The “Y” refers to the shape of the connection made with the stomach and intestines in this type of surgery.

Advantages of Gastric Bypass

• Typically most people will lose about 10 to 20 pounds in the first month after the surgery. Weight loss will continue but decrease over time. The people who see the best results are those who adhere to a strict diet and exercise routine, which is essential to keeping the weight off long term.

 In addition the following are benefits one can expect from gastric bypass surgery:

• Increased weight loss due to being a restrictive and malabsorptive surgery
• Verified long term success
• Insurance coverage is likely

Gastric bypass surgery not only has the obvious benefit of helping shed weight, but it can help improve a variety of medical conditions that are related to obesity.

• Type 2 Diabetes
• High Cholesterol
• High Blood Pressure
• Type 2 Diabetes
• Sleep Apnea
• Hypertension
• Joint Pain
• Asthma

Disadvantages of Gastric Bypass

• With any other major medical procedure, there is the potential for gastric bypass complications ranging from minor to major. It is understanding the potential for those risks and managing accordingly that will best help you get through anything that may come arise.
• Complex operation comes with risks including infection and bleeding
• "Dumping Syndrome" is associated with this procedure
• Potential for vitamin and nutrient deficiency due to malabsorptive component of this surgery

Restriction operations are the surgeries most often used for producing weight loss. Food intake is restricted by creating a small pouch at the top of the stomach where the food enters from the esophagus. The pouch initially holds about 1 ounce of food and expands to 2-3 ounces with time. The pouch's lower outlet usually has a diameter of about 1/4 inch. The small outlet delays the emptying of food from the pouch and causes a feeling of fullness.

After an operation, the person usually can eat only a half to a whole cup of food without discomfort or nausea. Also, food has to be well chewed. For most people, the ability to eat a large amount of food at one time is lost, but some patients do return to eating modest amounts of food without feeling hungry.

Restriction operations for obesity include gastric banding and vertical banded gastroplasty. Both operations serve only to restrict food intake. They do not interfere with the normal digestive process.

Restrictive operations lead to weight loss in almost all patients. However, weight regain does occur in some patients. About 30 percent of persons undergoing vertical banded gastroplasty achieve normal weight, and about 80 percent achieve some degree of weight loss. However, some patients are unable to adjust their eating habits and fail to lose the desired weight. In all weight-loss operations, successful results depend on your motivation and behaviors.

A common risk of restrictive operations is vomiting caused by the small stomach being overly stretched by food particles that have not been chewed well. Other risks of VBG include erosion of the band, breakdown of the staple line, and, in a small number of cases, leakage of stomach juices into the abdomen. The latter requires an emergency operation. In a very small number of cases (less than 1 percent) infection or death from complications can occur.

Gastric bypass operations (Roux-en-Y gastric bypass,Extensive gastric bypass (biliopancreatic diversion ) that cause malabsorption and restrict food intake produce more weight loss than restriction operations (Gastric Banding,Vertical banded gastroplasty (VBG) ) that only decrease food intake. Patients who have bypass operations generally lose two-thirds of their excess weight within 2 years.

The risks for pouch stretching, band erosion, breakdown of staple lines, and leakage of stomach contents into the abdomen are about the same for gastric bypass as for vertical banded gastroplasty. However, because gastric bypass operations cause food to skip the duodenum, where most iron and calcium are absorbed, risks for nutritional deficiencies are higher in these procedures. Anemia may result from malabsorption of vitamin B12 and iron in menstruating women, and decreased absorption of calcium may bring on osteoporosis and metabolic bone disease. Patients are required to take nutritional supplements that usually prevent these deficiencies.

Gastric bypass operations also may cause "dumping syndrome," whereby 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 so weak and sweaty that the patient must lie down until the symptoms pass.

The more extensive the bypass operation, the greater is the risk for complications and nutritional deficiencies. Patients with extensive bypasses of the normal digestive process require not only close monitoring, but also life-long use of special foods and medications.

Benefits

• 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.
• Surgery improves most obesity-related conditions. 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 had diabetes for a long time.

Risks

• Ten to 20 percent of patients who have weight-loss operations require followup operations to correct complications. Abdominal hernias are the most common complications requiring followup surgery. Less common complications include breakdown of the staple line and stretched stomach outlets.
• 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 is increased. Gallstones can be prevented with supplemental bile salts taken for the first 6 months after surgery.
• Nearly 30 percent of patients who have weight-loss surgery develop nutritional deficiencies such as anemia, osteoporosis, and metabolic bone disease. These deficiencies can be avoided if vitamin and mineral intakes are maintained.
• Many medications can be absorbed normally after gastric bypass surgery. But certain drugs, including some types of time-release medications, require careful monitoring in people who have had gastric bypass.
• Certain types of antidepressant drugs may also be affected by gastric bypass surgery. Following gastric bypass, some people may need to have their dose of antidepressant medication modified, or they may need to switch to a different type of antidepressant.
• In addition, medications designed to regulate a person's heartbeat and prevent an irregular heartbeat, called anti-arrhythmic drugs, need to be closely monitored in people who have had gastric bypass, as their absorption may change due to the surgery. The same is true for people who've had an organ transplant and are taking immunosuppressive drugs to prevent their bodies from rejecting the new organ. Their medication dosages should be followed closely.
• Even with drugs that require monitoring after gastric bypass, absorption should not be a major problem to overcome. In many cases, a change in dose or medication type is all that's needed.
• Women of childbearing age should avoid pregnancy until their weight becomes stable because rapid weight loss and nutritional deficiencies can harm a developing fetus.

Sources:

• http://www.advancebariatric.com/gastric-bypass.php
• http://www.wlscenter.com/ResearchArticles/Gastric_Surgery_Article.htm
• http://articles.chicagotribune.com/2012-02-09/health/sc-health-0208-gastric-drugs-20120208_1_stomach-pouch-controlled-release-medications
• http://www.webmd.com/diet/weight-loss-surgery/what-is-gastric-bypass-surgery
• http://www.webmd.com/diet/guide/is-weight-loss-surgery-right-for-you
• http://thebariatricsurgeryresource.com/
• http://www.mayoclinic.com/health/gastric-bypass/MY00825
• http://www.yourbariatricsurgeryguide.com/gastric-bypass-risks/