One man’s tragedy is another man’s triumph! No, I am not referring to the Super Bowl, or any other major sporting event for that matter. What I am referring to is gastric bypass surgery. More than 50 years ago this surgery was reserved as a last resort for patients to survive the tragic diagnosis of stomach cancer or severe ulcers.

Bariatric (weight loss) Surgery

The most common side effect of this drastic surgery was extensive weight loss. Today, more and more people without these life-threatening conditions are choosing to have this surgery for the sole purpose of experiencing this side effect. These procedures are now referred to as bariatric surgery.

Much like the reasoning behind having gastric bypass has evolved, so has the actual procedure. Initially, the majority of the intestinal tract was bypassed and weight loss was achieved through the malabsoption of calories. With the malabsoption of calories came the malabsorption of all nutrients, resulting in severe malnutrition that was sometimes fatal. Because of this, malabsorptive procedures are no longer performed.
Since then, a variety of bariatric surgeries have been developed to achieve more successful results. These surgeries can be categorized into 2 different types: restrictive and combined restrictive/malabsoprtive. In the following, I will review each type, revealing how they promote weight loss, as well as the risks, benefits, and effectiveness.

Restrictive Surgeries

People who choose restrictive surgery have the size of their stomach drastically reduced. This limits the amount of food that can be consumed without altering the absorption of nutrients. There are 2 different types of restriction surgeries: Adjustable Gastric Banding and Vertical Banded Gastroplasty.

Adjustable Gastric Banding

Known popularly as the “LapBand,” this type of restrictive surgery involves the placement of a hollow band around the upper end of the stomach. The band makes the stomach smaller and also creates a narrow passageway from the stomach to the intestines. The smaller stomach and narrow passageway result in a feeling of fullness with only a small amount of food.

The hollow band is filled with saline and can be adjusted by either adding or removing the saline. This allows patients the flexibility to either eat more or less, depending on their goals. The tube is initially placed in the hospital, requiring a 1-2 night stay. The tightness of the band can be adjusted in little time during an office visit.

Vertical Banded Gastroplasty

This type of restrictive surgery involved the stomach being made smaller using both staples and a band. The staples are used to partition the stomach to limit the amount of food that can be consumed. The band is used to tighten the passage from the stomach to the intestines, prolonging the amount of time someone feels full. Since the development of Adjustable Gastric Banding, Vertical Banded Gastroplasty is rarely used.

Effectiveness

People who undergo either type of restrictive surgery can expect to lose about half of their excess weight during the first year. Studies have shown that some of that weight will be regained in the 3-5 years after surgery. After 10 years, only 20% of patients achieve and maintain a normal weight. Weight gain has been attributed to patients eating soft, high calorie foods that can easily pass through the banded passageway.

Risks/Side Effects

Despite its effectiveness, restrictive surgery comes with risks and side effects. Vomiting is common when too much food is consumed or if the banded passageway becomes blocked with food not thoroughly chewed. Gallstones are also very common, and a result of rapid weight loss. However, supplements can be taken in order to avoid their formation.

Fifteen to 20% of patients who have restrictive surgery require a second surgery due to complications. These complications can be life threatening and include erosion of the band, breakdown of the staples, and /or leakage of saline or gastric juices into the abdominal cavity. Less than 1% of patients die after having restrictive bariatric surgery.

Combined Restrictive/Malabsorptive Surgery

People who choose a combined restrictive/malabsorptive surgery have both their stomach size and ability to absorb calories reduced. Reducing the size of the stomach eliminates the need to bypass a large amount of the intestines, making it much safer than the old malabsorptive surgeries. There are 2 types of combined suregeries: Roux-en-Y Gastric Bypass and Biliopancreatic Diversion.

Roux-en-Y Gastric Bypass

This surgery is similar to vertical banding in that the stomach is made smaller with both staples and a band. The surgeons reconnect the smaller stomach to the lower portion of the intestines. By bypassing the first sections of the intestinal tract, calorie absorption is greatly reduced. This procedure is the most common bariatric surgery performed.

Biliopancreatic Diversion

This is the most complicated of all bariatric surgeries. A Biliopancreatic Diversion involves part of the stomach being completely removed. The remainder is then reconnected at the last portion of the small intestine. This surgery can also be performed with a “duodenal switch,” allowing the patient to keep a larger portion of their stomach and the first part of their intestine (called the duodenum). This allows for a greater consumption of food and absorption of calories and nutrients.

Effectiveness

Patients who undergo combination surgeries can expect to lose about two-thirds their excess body weight in the first 2 years after surgery. Studies have shown that after 10 years, most people maintain about 60-80% of their weight loss. Those who have the Biliopancreatic diversion maintain a greater weight loss than those who have Roux-en-Y.

Risks/Side Effects

Because of their complexity, combined surgeries are more difficult to perform, and therefore, carry more risks. Twenty-eight percent of patients require a second surgery due to complications. This number is greatly reduced to 3% if the surgery is performed laproscopically versus openly. Laproscopic surgery requires only a few small incisions, while open surgery requires the opening of the entire abdominal cavity. Not only are complications less likely with laproscopic surgery, but also recovery times are greatly reduced.

Although the occurrence of malnutrition has been decreased with the evolution of bypass surgery, 30% of those who have a combined restrictive/malabsoptive procedure develop a nutrition deficiency. The most common deficiencies are calcium, iron, and vitamin B12. The absorption of calcium and iron occur in the first part of the small intestine (duodenum), which is most often bypassed. The absorption of vitamin B12 requires an enzyme that is produced in the stomach. Because the size of the stomach is significantly reduced, so is the ability to absorb B12.

“Dumping syndrome,” is another side effect of combined surgery, and can contribute to malnutrition. It involves diarrhea with associated dizziness, sweating, and heart palpitations. “Dumping syndrome” is a result of food moving too quickly through the shortened digestive tract.

Also contributing to “dumping” is the removal of the pyloris. The pyloris is the valve between the stomach and intestines that regulates how quickly the stomach empties. Without it, food is emptied from the stomach more rapidly. A duodenal switch keeps the pyloris intact, as well as the first part of the small intestine (dudenum), making both dumping and nutrient deficiencies less likely.

Benefits of Bariatric Surgery (Both Restrictive and Combined)

While there are many serious risks with having bariatric surgery, there are also quiet a few significant benefits. Most notable is the recent research showing a reversal of Type 2 Diabetes. However, it should be noted that the reversal of diabetes was attributed to the weight loss, and not the surgery itself. This means that weight loss, regardless of how it is achieved, can potentially reverse diabetes.

Along with diabetes, there are other medical conditions that have been improved with weight loss resulting from bariatric surgery. These include high blood pressure, sleep apnea, high cholesterol, and other risk factors that can contribute to heart disease. Improving these medical conditions can significantly improve quality of life and decrease the dependence on expensive medications.

The benefits of bariatric surgery do not come cheap. Surgery can cost around $20,000-$35,000, and may or may not be covered by insurance companies. Medical costs to correct complications related to bariatric surgery will not be covered by insurance, regardless of if the company covered the initial surgery. Patients are also responsible for the cost of the necessary nutritional supplements.

Is Weight Loss Surgery for you?

Bariatric surgery is not appropriate for those who are looking to lose a moderate amount of weight. In fact, just to be considered, an individual must have a BMI greater than 40, which is an excess of 100 pounds for a man and 80 pounds for a woman. Candidates also include those with a BMI between 35-40 with other medical conditions such as heart disease or diabetes.

f you meet all these criteria, and have the funds to finance this life changing surgery, it is still important to consult with a physician and a dietitian before deciding to have bariatric surgery.

Sources and additional information:

http://www.nlm.nih.gov/medlineplus/weightlosssurgery.html
http://www.mayoclinic.com/health/gastric-bypass/HQ01465
http://www.webmd.com/diet/weight-loss-surgery/surgery-for-you