Bariatric Surgery
(Severe Obesity)

*Bariatric surgery is a safe and effective treatment option for those affected by severe obesity. Moreover, these same procedures have also been recognized for their impact on metabolic or hormonal changes that play a major role in hunger (the desire to start eating) and satiety (the desire to stop eating) as well as improvement and/or resolution of conditions that can occur as a result of severe obesity. Bariatric surgery is a recognized and accepted approach for both weight-loss and many of the conditions that occur as a result of severe obesity; however, not all people affected by severe obesity will qualify for bariatric surgery. There are certain criteria that a person must meet in order to be a candidate for bariatric surgery.

*Please Note: It is important to note that there are risks involved with bariatric surgery, as well as any other surgical procedure. Before making a treatment decision, it is important to discuss these risks with your primary care provider and/or surgeon. The OAC also encourages individuals to discuss these risks with their family members. To maintain consistency throughout our materials, total body weight-loss is used when comparing all surgical treatment options. You may encounter other post-surgery materials that report/discuss weight-loss as “excess body weight.” For accuracy, be sure to ask your provider what method they’re reporting when discussing surgical options for weight-loss.

Indications:
At the 1991 National Institutes of Health (NIH) Consensus Conference, bariatric surgery was considered an accepted and effective approach that provides consistent, durable weight-loss for individuals affected by severe obesity. Furthermore, the NIH identified several criteria for candidacy for bariatric surgery, including:

Body Mass Index (BMI) = a number calculated based on a person’s height and weight:
BMI >40, Severe obesity (or weighing more than 100 pounds over ideal body weight)
BMI 35-40 with significant obesity-related conditions (type 2 diabetes, high blood pressure, sleep apnea or high cholesterol)
No endocrine causes of obesity
Acceptable operative risk
Understands surgery and risks
Absence of drug or alcohol problem
No uncontrolled psychological conditions
Failed attempts at medical weight-loss (diets, other weight-loss options)

Consult with your primary care provider (PCP) and insurance provider to see if you are a candidate.

Benefits:
Within two to three years after the operation, bariatric surgery usually results in a weight-loss of 10 to 35 percent of total body weight, depending on the chosen procedure. Those considering bariatric surgery should talk to their PCP about what their personal expectations should be for loss of excess weight. In addition, co-morbidities, such as diabetes, high blood pressure, sleep apnea and others are often reduced or may go into remission. Most will find they require fewer medicines throughout time and many will discontinue their medicines completely.

Risks:
Research indicates that some patients who undergo bariatric surgery may have unsatisfac­tory weight-loss or regain much of the weight that they lost. Some behaviors such as frequent snacking on high-calorie foods or lack of exercise can contrib­ute to inadequate weight-loss. Technical problems that may occur after the operation, like separated stitches, may also contribute to inadequate weight-loss. There are also other potential complications that may occur which have been listed below with each of the various procedures.

Remember, bariatric surgery is not the “easy way out.” This treatment option is a tool that patients use to lose weight. Surgery is a resource to help reduce weight and maintain weight-loss. Lifestyle adjustments encompassing behavioral, diet, physical activity and psychological changes are required for you to maintain a healthy quality of life. Continued positive weight-loss relies upon your desire and dedication to change your lifestyle with a proactive approach.

Throughout this section, you will see terms, such as “metabolic,“ “non-metabolic,” “laparoscopic” and “open,” in which you may not be familiar. Prior to reading about the different surgeries, we have provided you with a brief description of some of the most commonly used terms when talking about bariatric surgery.

Open vs. Laparoscopic Procedures

In each section, you will see the surgeries described as being performed “open” or “laparoscopic.” Although the laparoscopic procedure has increasingly gained in popularity and frequency, open procedures are still used in practice today. The approach will depend on several factors, including surgeon experience as well as your surgical and medical history, which may influence one approach to be used over the other. Please be sure to discuss the surgical approach with your surgeon.

“Open” – The open procedure involves a single incision that opens the abdomen, which provides the surgeon access to the abdominal cavity. The incision can vary in length from as little as three inches to as large as six or more inches.

“Laparoscopic” – In laparoscopic surgery, a small video camera is inserted into the abdomen allowing the surgeon to conduct and view the procedure on a video monitor. Both camera and surgical instruments are inserted through small incisions made in the abdominal wall. The number of incisions will vary depending on the surgical procedure and surgeon experience. Some surgical procedures can be performed via a single incision while other procedures may involve six or more small incisions.

Metabolic vs. Non-metabolic

The operations in this group help patients lose weight by altering their gastrointestinal tracts. Examples include the vertical sleeve gastrectomy (VSG), Roux-en-Y gastric bypass (RNYGB), and the biliopancreatic diversion with duodenal switch (BPD/DS).

“Metabolic Operations” – The operations in this group help patient lose weight by altering their gastrointestinal tracts. By doing this, it changes the patient’s physiological response to fat loss. After metabolic surgery, there is a change in the way that gut hormones are secreted. The result is that after surgery, in the face of fat loss, patients don’t have to fight their hunger which is helpful when attempting to lose weight.

Recent research indicates that each bariatric surgery works not only through the anatomical and mechanical changes from the procedure itself, but through metabolic changes in the “gut hormones.” Numerous studies have examined pre-operative and post-operative gut hormone levels after bariatric surgery. A brief summary of hormonal changes after each bariatric procedure is provided in the next sections. Some of these hormones are:

Ghrelin: functions primarily to stimulate appetite
Glucagon-like peptide 1 (GLP-1): mechanism of action includes increased satiety and reduced stomach emptying
Peptide YY (PYY): reduces appetite and increases efficiency of digestion and nutrient absorption

“Non-metabolic Operations” – The options in this group provide significant weight-loss without altering the physiology of energy (fat) storage. Examples include the laparoscopic adjustable gastric bands (LapBand® and the Realize Band®) and Neuromodulation (VBLOC®). They are considered non-metabolic options because they do not alter the body’s normal mechanisms that occur when dieting. With bandings and with dieting, orexigenic hormones increase and anorexigenic hormones decrease.