Bariatric and Metabolic Surgery

Obesity is a worldwide problem of increasing prevalence. Ideally, and in its less severe stages, obesity can be controlled with diet management and a regular exercise program. At times, obesity may be so severe that it is termed morbid obesity.

When should I consider Bariatric Surgery for Weight Loss?

Morbid obesity is the weight at which diet and exercise are not enough and surgical options should be considered. Candidates for weight-loss surgery have typically failed a regimented and organized diet program. The length of this organized diet program varies across practitioners and insurers. Dr. Belsley typically recommends a minimum of a 3 month program performed with your primary care doctor even if your insurance carrier does not have a time requirement. Other criteria include an organized set of measurements that has varied over time with one of them representing an estimate at about 100 pounds over your ideal body weight. Something to remember, however, is that is not acceptable to undergo bariatric surgery if you suffer from untreated depression or any other major psychiatric disorder. Ideally you will be at a time and place in your life when you want to improve.

A personal look at obesity and its problems

A woman measuring her waist to hip ratio
Every person has a slightly different set of reasons for thinking about metabolic weight-loss surgery. Being 100 pounds overweight and wanting a change is not enough. Success requires proper support, commitment to diet and exercise, as well as approrpriate timing when life is already full of responsibilities.

How is Morbid Obesity Defined?

Obesity is a worldwide problem of increasing prevalence. Ideally, and in its less severe stages, obesity can be controlled with diet management and a regular exercise program. At times, obesity may be so severe that it is termed morbid obesity.

Medically, the term, morbid obesity is defined as a body mass index (BMI) greater than 40 kg/m^2. Although this calculation depends upon both an individuals height and weight, persons who are approximately 100 pounds over their ideal body weight are likely to be morbidly obese. Depending on the study, estimates for obesity in America may suggest that up to 35% of adults (or one in every three) suffers obesity and that from between 3-7% of the adult US population currently suffers from morbid obesity.

Several life-threatening complications such as diabetes , high blood pressure and coronary artery disease are associated with this condition. Medical weight reduction practices often do not yield good results in these situations. Surgical intervention may be indicated to stop weight gain, achieve weight loss and reverse some of the obesity-related medical conditions described above.

Weight loss surgery, including gastric bypass and the laparoscopic gastric sleeve are surgical procedures whose utility in combating morbid obesity are recognized by both medical and surgical specialists. Patients who have a BMI greater than 40 or those with a BMI of 30 or more who are also suffering from life-threatening illnesses curable with weight loss are considered as possible candidates for bariatric surgery.

The United States government also supports bariatric surgery in appropriate candidates, as Medicare will cover the costs of both the gastric bypass and the laparoscopic sleeve in appropriate candidates. Although the criteria that insurance carriers look for in determining whether or not an individual warrants this surgery vary, doctors generally agree on a set of qualifying criteria. The decision to proceed with surgery always represents a comparison between risks and benefits, as any surgical procedure involves some risk. Generally accepted criteria for proceeding with this type of surgery include that an individual have been obese for at least two years, be between the ages of 18 and 65 years and have no medical or psychiatric contraindications to undergoing surgery. Many surgeons will consider offering surgery both for younger and older patients than suggested above.

Obesity limits daily function

An obese person with difficulty getting out of a compact car.
Morbid obesity is not just an inconvenience. Morbid obesity is a disease that shortens the average lifespan and also limits mobility and societal routines that many of us take for granted.

Obesity is a serious disease with symptoms that build slowly over an extended period of time. The National Institutes of Health (NIH) define morbid obesity as: Being 100 pounds or more above your ideal body weight, or having a Body Mass Index (BMI) of 40 or greater, or having a BMI of 30 or greater and one or more co-morbid conditions. Other societies have defined morbid obesity to be a BMI with one or more co-morbid conditions.

The disease of morbid obesity interferes with basic physical functions such as breathing or walking. Long-term implications of the disease include shorter life expectancy, serious health consequences in the form of weight-related conditions such as type 2 diabetes and heart disease, and a lower quality of life with fewer economic and social opportunities.

What are Obesity Related Co-morbid Conditions?

Bariatric surgery may improve some pre-existing health conditions. The presence of obesity increases the risk of a number of medical conditions, including cancer. A co-morbid condition is a health condition related to a primary disease such as obesity. There are many health conditions related to morbid obesity but some of the most common are:

Type II diabetes, heart disease and high blood pressure, high cholesterol, obstructive sleep apnea, acid-reflux, cancer, depression, osteoarthritis and abnormal menses are all examples of obesity related co-morbid conditions.

Bariatric surgery can also help women become pregnant and have healthier pregnancies. Weight-loss and dietary change can cure certain elements of PCOS and often times irregular menses begin to normalize and fertility improves. An emerging body of literature demonstrates relationships between maternal obesity and structural birth defects, including an increased risk of spina bifida and heart defects. These conditions occur more frequently in people with morbid obesity.

It is very important to not become pregnant for approximately two years after bariatric surgery. Although proper fetal nutrition can be achieved with careful follow-up and vitamin supplementation, pregnancy may reduce the ultimate weight-loss associated with bariatric surgery and the difficulties with radiological imaging during the pregnancy can make discerning possible complications very difficult.

Who Succeeds with Bariatric Surgery?

Long-term success after bariatric surgery is achieved by those who find internal motivation for success and understand that bariatic surgery is a finite tool that can help them achieve their weight-loss goals.

Bariatric surgery can help patients effectively and permanently improve their health. Bariatric surgery restricts the amount of food patients can eat and, and depending on the procedure, the number of calories and nutrients the body can absorb. The patients that succeed typically use the surgery as a tool to help them realize and change their previous destructive cycle of bad food behavior.

Bariatric surgery should not be considered until you and your doctors have explored dietary weight-loss and lifestyle change. Bariatric surgery is not cosmetic surgery and that it does not involve the removal of adipose tissue (fat) by suction or surgical removal. You must understand the benefits and risks and commit to long-term lifestyle changes, including diet and exercise, which are key to the success of bariatric surgery. Complications after surgery may require further operations.

Restriction, Malabsorption and Hormonal Change

The Gastric Bypass

Illustration of the laparoscopic gastric bypass
The gastric bypass is thought to provide greater weight loss than the sleeve and to avoid long term problems with acid reflux.

There are several different bariatric surgery procedures, but the two general ways in which they work are restriction and malabsorption:

Restriction limits the amount of food you can eat. The surgically-created, smaller stomach pouch that is created in both the gastric bypass and the gastric sleeve, restricts the amount of food that can be eaten at one time and also ensures that the patient feels satisfied with less food.

Malabsorption limits the number of calories and nutrients your body can absorb. During malabsorptive procedures, the surgeon reroutes the small intestine so that fewer calories and nutrients are absorbed.

The laparoscopic gastric bypass and the laparoscopic gastric sleeve have many similarities and differences. The skin incisions used to perform the laparoscopic operations are so similar that a doctor can often not tell which operation you have had just by looking at the incisions on your skin.

Patients who undergo bariatric surgery, either laparoscopic gastric bypass or the laparoscopic gastric sleeve, experience significant weight loss after surgery. Both operations decrease the size of the functional stomach, causing an individual to feel full faster. This lowers the amount of food that one consumes and can significantly lower the number of calories consumed.

The Gastric Sleeve

Illustration of the laparoscopic gastric sleeve
The gastric sleeve does not require re-routing of the intestines nor any new intestinal connections however it does require that a significant portion of the stomach is permanently removed.

There are many important differences concerning how your intestinal system is changed on the inside. Even though the cuts on the outside of the skin are small, both operations involve cutting the stomach permanently and are associated with real surgical risk. Both operations seem to have positive temporary hormonal effects on satiety and hunger. These positive effects only last about one year at which point you will have hopefully come close to a new healthier weight; you will need to rely on lifestyle modification to maintain your long-term weight loss.

How Does Bariatric Surgery Help Weight-Loss?

Bariatric surgery works by helping you restrict the number of calories that you consume. A healthy restrictive diet is very important and must be followed even after the operation. To lose weight, your body must burn more calories than you eat and/or drink. A diet plan should be based on your health and lifestyle needs, and would include reducing the number of calories you take in.

Is Diet or Exercise More Important for Weight-Loss?

Dietary restriction is likely more important for weight-loss than burning calories with exercise. Frequent and regular physical activity is beneficial to most anyone—whether they are pre- or post-surgery. Generally, an exercise program includes cardiovascular exercise such as walking, swimming, or cycling, strength training using resistance bands, weights, or machines, and stretching. Speak with your primary care physician before beginning any physical activity.

Exercise comes in many forms

Resistance band exercises are low-impact and strengthen the core and extremities.
Exercise and an active lifestyle are both important elements of maintaining a healthy weight. At the beginning be sure to choose low impact activities that protect your joints. You will find that as the pounds start to come off, exercise will become more enjoyable and fulfilling.