Weight Loss Surgery Offers a Long-Term Solution

One of the reasons more and more people are considering weight loss surgery is that chronic obesity is hard to treat with diet and exercise alone. Many people, who are candidates for weight loss surgery, cannot lose weight and keep it off by using traditional means. In addition, these people suffer from serious obesity-related health problems.

Surgical treatment may sound drastic, but in fact, such procedures have been in use for years and are becoming increasingly common. According to the latest data from the American Society for Metabolic and Bariatric Surgery (ASMBS), the estimated number of weight loss surgeries performed in the United States in 2007 was 205,000, which is a significant increase over the estimated 177,600 in 2006. The steady rise in weight loss surgery numbers can be attributed to the numerous modifications made to earlier procedures over the last few decades, which have produced safer and more lasting options for surgery.

Long-Term Weight Loss Is Associated with Improvements in Health
Perhaps what is most important to note is that clinical studies have shown weight loss surgery to be successful in achieving substantial, long-term weight loss, as well as marked improvements in weight-related health conditions. In one study that examined how the adjustable gastric band procedure using the LAP- BAND® System affected diabetes in severely obese, type 2 diabetic adults, patients experienced progressive weight loss over the first two to three years. After two years, the average percentage of excess weight loss was better than 50 percent. The weight loss significantly improved all measures of glucose metabolism with the remission of diabetes occurring in 64 percent of patients. Additionally, weight loss was associated with significant improvements in cholesterol levels, high blood pressure, sleep, depression and overall quality of life. The results of this study are mirrored in numerous others. Within the first two years of surgery, you can realistically expect to drop half of your excess weight.

You can also expect to keep the pounds off in the long-term— if you do the work. Surgery is one part of an overall treatment plan, and reaching a healthier weight requires a great many behavioral changes. Whether surgery succeeds is largely dependent upon your commitment to lifestyle changes afterward.

Weight Loss Surgery Options
Currently, the procedures fall into three major categories.

1. Restrictive Procedures
In these operations, a surgeon creates a small pouch about the size of a walnut, at the top of the stomach where food enters from the esophagus. The pouch holds approximately 2 ounces of food. The lower outlet in the pouch is usually half an inch in diameter or even smaller. This tiny outlet slows the emptying of food from the pouch to the larger area of the stomach. This creates a prolonged sense of fullness with very little food.

Adjustable gastric band surgery is a type of restrictive procedure and is less invasive and safer weight loss surgical approach. While it is performed less frequently than gastric bypass surgery (described below), adjustable gastric banding procedures are increasing since their approval in the United States in 2001.

In adjustable gastric banding, an inflatable band made of silicone 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 saline solution (salt water) through a tube that connects the band to an access port placed under the skin. The port allows your doctor to loosen or tighten the gastric band over time to adjust the rate of weight loss for each person's needs.

2. Malabsorptive Procedures
Malabsorptive procedures shorten the digestive tract to limit the number of calories and nutrients that can be absorbed.

Biliopancreatic diversion (BPD) is a malabsorptive procedure in which the lower portion (three-fourths) of the stomach is removed and the small pouch that remains is stapled directly to the small intestine. The biliopancreatic diversion greatly reduces nutrient absorption and caloric intake, but is used less often than adjustable gastric banding and gastric bypass (described below), because it entails a high risk of nutritional deficiency, as well as higher operative complications and death rates.

3. Combined Restrictive/Malabsorptive Procedures
These are the most commonly used weight loss procedures in the United States because of their longer history in this country. They restrict the amount of food you can eat and reduce the amount of calories the body absorbs.

In a gastric bypass (also known as Roux-en-Y gastric bypass), the surgeon creates a small stomach pouch that can hold only limited amounts of food. Then a Y-shaped section of the small intestine is cut and attached (usually by stapling) to the pouch to allow food to bypass the lower stomach entirely and the first two sections of the small intestine. This reduces the amount of calories and nutrients the body can absorb.

Adjustable gastric banding, gastric bypass and less commonly biliopancreatic diversion, can be performed through laparoscopic surgery, which is a technique that eliminates the need for a large incision. Several small incisions are made, which allow the surgeon to pass a light, camera and special surgical instruments into the abdomen. The surgical instruments are long and narrow, usually about the width of a pencil, which allows them to pass easily through the small incisions. The small incisions result in less loss of blood, shorter hospitalization, a faster recovery and fewer complications, as compared with traditional surgery. However, gastric bypass and biliopancreatic diversion are more difficult to perform laparoscopically than adjustable gastric banding and can create serious problems, if performed incorrectly.

Recovery Time and Potential Complications
Recovery time and surgical complications vary with the type of weight loss surgery. Adjustable gastric banding is associated with the shortest recovery time, with hospitalization after surgery usually lasting less than 24 hours. With the combination procedures, you should expect to be in the hospital for three to five days, or two to three days with the laparoscopic procedure. With all of these procedures, you will need a new nutrition plan after surgery and you will follow a specific dietary progression for about 12 weeks. This dietary progression begins with a liquid diet and ends with small meals of healthy, solid food.

Weight loss surgery is major surgery, and as such, it comes with the risks of bleeding, infection and an adverse reaction to anesthesia. In rare cases, patients have died. However, significantly lower rates of medical complications and mortality have been associated with adjustable gastric banding compared with gastric bypass and BPD surgery.

Other potential complications include blood clots in the legs, which are more likely to occur in very overweight people. With all surgical procedures that utilize stapling, which are combined restrictive/malabsorptive procedures, a patient can develop leaks or separations at the staple line in the stomach, a problem that can be treated with antibiotics or may require major surgical repair. Pneumonia, narrowing of the opening between the stomach and the small intestine and vitamin and nutrient deficiency (mostly in gastric bypass and BPD) have also been noted.

Is Surgery an Option for You?
Of course, weight loss surgery isn't right for everyone who has a weight problem.

If you have a body mass index (BMI) of 40 or more, you may be a candidate; this means men who are roughly 100 pounds or more overweight, or women who are at least 80 pounds overweight. People who have a BMI of 35 or greater and also have at least one weight-related health problem, such as diabetes, cardiovascular disease or osteoarthritis, may also be candidates.

It's vital for anyone considering weight loss surgery to have a realistic understanding of the operation and its risks, as well as the lifestyle changes that will be necessary afterward. So talk to your surgeon to get the answers you need for making what could be the most important decision of your life. For the right candidate, surgery may offer the best hope for a healthier life.

References
1.   Grundy SM, Barondess JA, Bellegie NJ, et al, Consensus Development Panel. Gastrointestinal Surgery for Severe Obesity. National Institutes of Health Consensus Development Conference Statement. March 25-27, 1991.
2.   American Society for Bariatric Surgery (ASBS). 2005 Excecutive Survey.
3.   O'Connell T. An overview of obesity and weight loss surgery. Clin Diabetes. 2004;22:115-120.
4.   Dixon JB, O'Brien PE. Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes Care. 2002;25:358-363.
5.   Mayo Clinic Staff. Gastric bypass: is this weight-loss surgery for you? Mayo Clinic Web site. Available at: http://www.mayoclinic.com/health/gastric-bypass/HQ01465. Accessed March 22, 2006.


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